Queensland Health Under Fire Over Handling of Suicidal Patient on Gold Coast

In June 2025, a sobering report cast serious doubt on the quality of care provided by Queensland Health after a young man with suicidal ideation was discharged from a Gold Coast hospital—despite his mother repeatedly urging clinicians to keep him under supervision.

The independent review found that the young patient had shown clear suicide warning signs before being sent home, raising pressing concerns about clinical decision-making and systemic lapses. The patient returned shortly thereafter and later died, prompting investigators to critique the discharge as premature and ill‑informed.

A whistle‑blower, clinical nurse and patient safety officer Tanya Silkin, alleged she was dismissed after calling attention to interference with a Root Cause Analysis (RCA) into the patient’s death. She said her independent RCA—which is meant to be carried out by objective experts in protected settings—was replaced with a less rigorous internal review that limited staff from speaking openly, especially in front of their managers. Silkin argued these "comprehensive reviews" lack the legal safeguards and thoroughness of official RCA protocols.

Silkin described being sidelined after returning from medical leave, during which her draft RCA was altered into what appeared to resemble a template-based review. Soon after, she was placed under disciplinary action—ostensibly for taking too much leave—and accused of breaching privacy by accessing emails at home. She ultimately lost her job and chose not to pursue full legal action due to cost constraints.

The patient’s family, meanwhile, were told the internal assessment found the discharge decision appropriate, noting that capacity assessments had been completed and that least‑restrictive care protocols were followed. However, the parents remain deeply upset that they were denied access to the RCA report, which, under the law, they were entitled to obtain. They say the review dismissed the gravity of their son’s condition, minimised his suffering, and diminished his memory.

Advocacy groups and mental health professionals say the case highlights broader structural failures in Queensland’s public mental health system. Ongoing staff shortages, ageing psychiatric wards described as "no longer fit for purpose," and a lack of sufficient bed capacity across the state have all been flagged by recent inquiries.

Between December 2022 and April 2024, three patients died by suicide in a locked mental health unit at Brisbane’s Prince Charles Hospital, prompting a state-commissioned review that found the facilities unsafe and under-resourced. It delivered 22 recommendations, focused on improving infrastructure, staffing, and therapeutic programming. Despite these findings, professional groups estimate the system remains short by approximately 3,000 mental health staff and 370 beds across Queensland.

In addition, Queensland faces one of Australia’s highest suicide mortality rates—14.1 per 100,000 people in 2023—and intentional self-harm hospitalisation rates nearly 45% above national averages, particularly among teenagers and residents in remote or socioeconomically disadvantaged areas.

Calls are mounting for greater government transparency, reinforcement of independent RCA protocols, and stronger protections for whistle-blowers. Employee advocacy bodies also warn of a culture that discourages staff from raising safety concerns, citing fear of reprisals or burnout as key deterrents to open reporting.

Looking forward, policymakers face a difficult task: how to rebuild trust in Queensland Health’s mental health services, ensure accountability in adverse outcomes, and deliver on much-needed investments in personnel, infrastructure, and crisis care capacity. This includes addressing the often-overlooked need for accessible, short-term hospital accommodation—especially for regional patients and families who must travel long distances for psychiatric care. Without reliable places to stay during or after treatment, continuity and equity in care may suffer.

The community, advocates, and affected families await meaningful action as the report’s implications reverberate across the state’s testing mental health system.