Questions have been raised about the death of a man who was in hotel quarantine before he died by suicide, after a coroner found the "unsophisticated" quarantine system left him without proper medical care.
Brendan Luxton died a day after he was released from two weeks of mandatory hotel quarantine in Brisbane in July, 2020.
Mr Luxton's family, recognising his deteriorating mental health, repeatedly contacted Queensland Health on his behalf for a medical exemption.
The coroner's report into Mr Luxton's death, released to his family and the Metro North Health Service, outlines where the system failed.
"The report was horrendous to read," his sister Marita Corbett said.
"There were six very strong red flags that were missed by Queensland Health… probably most distressing for us was the claim by one of the people involved in the process that she felt pressured to 'not remember' what happened."
"I understand the system was overwhelmed. But in this case, the system didn't exist first. They ran a process on spreadsheets and sticky notes, that is not a system."
The coroner said an Australian army officer who made a check-in call to Mr Luxton towards the end of his two-week quarantine had felt pressured to lie about what happened.
The report details the process to refer people for further help as writing the individual's name, hotel and room number on a sticky note and placing it on the mental health nurse's desk — with no method to follow up.
"She felt pressure from Metro North Public Health Unit to respond to the request for information from the Coroners Court with a suggested response of, 'I do not recall'," the report said.
Health Minister Yvette D'Ath — who was not the minister responsible at the time — said the allegation was "a serious issue" and would be subject to investigation.
"In the report there was one individual who was seconded in from the defence force who felt pressured relating to her response to the court," Ms D'Ath said.
The minister said Queensland Health and Hospital and Health Services would investigate the claim and "reach out to the individual to see if they're willing to be interviewed".
Mrs Corbett said she didn't trust Queensland Health to investigate the matter.
"I don't have the faith that it will be independent or objective. Why would you let a child mark their own homework?"
"It needs an independent Royal Commission to go beyond just the quarantine in the hotel, it's the full impact of how we managed COVID."
Both Ms D'Ath and the Director-General of Queensland Health Shaun Drummond have dismissed the need for a Commission of Inquiry, referring to Queensland Health's history of reviewing its COVID-related processes.
Exemption not submitted to CHO
Mrs Corbett lodged an official request with the department warning of her brother's mental condition and laid out a COVID-safe plan for him to spend the remainder of his quarantine period at her house.
When no action was taken she emailed Premier Annastacia Palaszczuk, a childhood friend of Mr Luxton's.
But ultimately Mr Luxton was not granted an exemption and was released from hotel quarantine on July 16, 2020. He died a day later.
The coroner's report details how Mr Luxton's exemption was triaged as being "urgent 24 hours" the day after it was received — but wasn't handed over to another staff member when the person handling it went on leave three days later.
The application was not submitted to the Chief Health Officer for consideration and determination.
On the weekend that Mr Luxton's application was submitted, there were 386 requests for exemption made — many of them were prioritised as "urgent".
The coroner concluded Mrs Corbett did "everything she could" to seek exemption and offered an appropriate alternative which would have enabled Mr Luxton to be isolated at her home, where he would be able to access family support, supervision and access to urgent mental health care.
"His family had persistently attempted to communicate the urgency of the application and Brendan Luxton's precipitous deterioration of his mental health during this period of quarantine," the coroner said.
"Their efforts were unheard."
The coroner described the system in place in hotel quarantine as "unsophisticated" and didn't trigger a review when someone was repeatedly unavailable for check-in calls, or sought emergency assistance.
Ms D'Ath said there were "lessons to be learned" from the report.
"It's obviously a really distressing time for the family and our condolences go out to them as they did at the time of Mr Luxton's passing," Ms D'Ath said.
"We know that during COVID and hotel quarantine there was incredible pressure on the system and our health workers worked really hard to provide the best care that they could.
"As the report has shown, changes started to be made to the system after this tragic event so we could learn from it."
Ms D'Ath said the coroner did not find any one individual responsible for Mr Luxton's death.
"Managing anyone with mental health is complex, and lessons were learned out of what occurred about supporting people … particularly around exemptions at the time, where it was changed so that there could be different people delegated to consider applications so they could be dealt with more speedily."
Mr Luxton's family said they have not heard from directly from the Premier.
Mrs Corbett was dismayed to hear the premier mention their brother's death in a mental health funding announcement in August 2020.
"Just recently I had an email from someone mentioning that a lovely man I went to school with, primary school, had sadly lost his life," the premier said at the time.
"And the email to me was essentially that COVID can take its toll on many people."
