South Australia’s coroner has found the state’s mental health system failed an acutely psychotic woman in the months before she killed her two-year-old son.
Duke Hadley was asphyxiated when his mother Rachael Hadley stood on his face and chest at their Royal Park home in Adelaide’s north-west in November 2009.
She claimed she wanted to ward-off evil spirits and was found not guilty of murder because of mental incompetence.
“The system failed to provide an intervention that might have saved this young boy,” he found.
Ms Hadley was admitted to the Queen Elizabeth Hospital in December 2008 and a psychiatric examination noted she was hearing voices and suffering from “persecutory beliefs”.
She was discharged later that month and her care was left in the hands of the Port Adelaide Community Treatment Team.
Mr Johns found the team’s last contact with her was in February 2009, about eight months before she killed her son, and her file was closed in September.
“Whether that failure was causative of Duke Hadley’s death is a matter on which it is not possible to reach a conclusion, given the amount of time that passed between Ms Hadley’s contact with the team and Duke’s death,” he said in his findings.
“It is not unreasonable, however, to speculate that had Ms Hadley been afforded proper and appropriate psychiatric care, she may not have relapsed and deteriorated to the point of the acute psychotic condition she suffered at the time of Duke’s death.
“On any view it is extremely disturbing that the mother of a two-year-old child would be the subject of such a serious breakdown in the mental health system in February, and would be arrested for the violent murder of that child the following November, and yet that is what happened in this case.
“The breakdown that led to the cessation of contact between the Port Adelaide Community Treatment Team and Ms Hadley was unacceptable and should not have happened.
“In my opinion it is a result of the unrealistically high workload that the Port Adelaide Community Treatment Team had at that time.”
Phone call night before death makes ‘harrowing listening’
The night before he died, the toddler’s father Jason Hura phoned the Mental Health Triage Service as Ms Hadley’s mental state deteriorated.
“I was desperate for help,” he said.
“I rang emergency service, it’s a 24-hour emergency service and they said they didn’t have anyone [who could] come out at that time.
“They would have seen how ill she was and taken her away.”
Mr Johns said “the conversation between [the operator] and Mr Hura makes harrowing listening” and “sounded as if the person taking the call was trying to find reasons not to help.”
“Once again, the system failed to provide an intervention that might have saved this young boy.”
But Mr Johns said he did not want to be “unduly critical” of the operator who was “was working in an environment in which he felt more obliged to ration a precious resource, than to be encouraging of Mr Hura’s efforts to obtain care for Ms Hadley.”
Mr Johns made several recommendations for reforms to the mental health system.
“There is no substitute for adequate resourcing,” he said.
“The mental health system as currently structured does not ensure continuity of care, and … this should be addressed as a matter of priority.”
Mr Johns advised that “community mental health teams, such as the Port Adelaide Community Treatment Team, [be] regularly audited to ensure that they are adequately and appropriately staffed and have systems to track patients and to track appointments.”
Mr Hura hopes others are spared similar experiences to his.
“It’s pretty bad from what I’ve seen over the last four years. It needs to change before this keeps happening because it’s going to keep happening,” he said.
“Everything needs to change.”
This article first appeared on ‘ABC’ on 31 January 2014.