The Office of the Health Ombudsman (OHO) commenced a systemic investigation following a complaint about the services provided as part of a private residential retreat program to a consumer who passed away due to suicide in the days following the suspension of her program. The consumer had a history of hospital admissions for mental health treatment, including in the months prior to entering the private residential retreat program, however did not fully disclose this to the provider. The consumer’s mental health deteriorated during her stay and, following consultation with her external treating practitioner, it was recommended by the private residential retreat provider that the consumer’s program be suspended until she was well enough to participate fully in the program. The consumer passed away by suicide in the days following her exit from the retreat.

Wider learnings and recommendations for service improvements

The investigation identified opportunities for improvement and proposed recommendations relating to:

• Development of introductory material for engagement with third party treating practitioners, where consent is obtained to facilitate such communication and the communication is warranted.
• Improvements to internal procedures to ensure clinical review and evaluation of material received from third party treating practitioners.
• Strengthening processes for review of consumers at moderate or high risk of suicide or self-harm.
• Improvements to discharge processes including documentation around risk assessments and communication with third party treating practitioners.

Read the snapshot report (PDF 122KB)