The mother of a 13-year-old girl who died moments after a mental health appointment says she is still searching for answers that can only be found through a coronial inquest.
Kate Savage died from self-inflicted injuries shortly after she left an appointment with the Child and Adolescent Mental Health Service (CAMHS) in July last year.
Meron Savage described her daughter as "an amazing, talented girl with her whole life ahead of her".
They had just chosen paint to redecorate her bedroom, as well as new furniture and accessories to match the theme, when Kate died.
During the last six months of her life, Kate attended the emergency department at Perth Children's Hospital (PCH) on 11 occasions and had seven admissions.
A report by WA's Chief Psychiatrist Nathan Gibson, released last year, found there had been missed opportunities to change the course of Kate's life, including by much earlier intervention, after she was first referred to CAMHS in 2015.
My last chance to learn truth: mother
Ms Savage this year obtained hundreds of pages of Kate's medical records through Freedom of Information.
She said the records highlighted the need for a coronial inquest to examine Kate's medical care over several years.
Ms Savage said the Coroner's Court had indicated there would likely be an inquest into Kate's death, but it was yet to confirm its decision.
"If they come back and say we are not going to do an inquest, I don't know if I will ever really know.
"There are so many things that should never have happened that just really need to be looked at."
After the coroner confirmed an inquest would be held into the death of Aishwarya Aswath at Perth Children's Hospital earlier this year, the state government announced it would be fast-tracked.
Ms Savage said Kate's inquest should be treated with the same urgency.
"It is not just in my daughter's interest or in our family's interest to get answers for us, but it is also in the public interest," she said.
Kate's death drives change
Dr Gibson's report found CAMHS was struggling to respond to the steep growth in self-harm, suicidal ideation and attempted suicide in young people, primarily those aged 13 to 17 but also in younger children.
"What this reflects is a significant problem of chronic under-resourcing of CAMHS, associated with a rise in demand for services for high-risk adolescents which has led to the need to ration services, particularly for children in the 0-12 age group," his report stated.
Dr Gibson found there was a significant difference between the views of the clinical team treating Kate and her parents, in terms of her risk of suicide.
"Kate's early history highlights the opportunities that existed, particularly after her first contact with CAMHS, to potentially change the course of her life," he found.
His report outlined seven key recommendations that included immediately appointing a child and adolescent mental health ministerial taskforce to redesign and rebuild the CAMHS system.
A spokesperson for the Child and Adolescent Health Service (CAHS) said four of the remaining six recommendations had been implemented:
- An independent review process for cases where there is difference of opinion between clinicians and families;
- Urgent expansion of the clinical workforce with a focus on community CAMHS
- Review of guidelines for management of Emotionally Unstable Personality Disorder in adolescents
- Resourcing of CAMHS emergency service to allow 24/7 operation
The spokesperson said work was also continuing to fully implement the remaining two recommendations:
- Dedicated positions for family peer workers to improve the relationship between families and staff
- A model of care for a community intensive treatment service
In its annual report, CAHS stated that the deaths of Kate Savage and Aishwarya Aswath had led it to re-examine staffing, training and support, and reporting and monitoring processes and equipment.
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