At 17 years old, he was captain of his Alice Springs high school, year 12 dux, and a talented athlete who appeared to have the world at his feet.
The “intelligent”, “impressive young man” had received multiple academic awards and had been selected to represent the Northern Territory in athletics.
Then in 2023, he took his own life.
Behind all his achievements, life at home for the boy — referred to at an inquest into his death held last year by the initials RL — had been unravelling.
The coroner’s court heard 17-year-old RL started struggling with his school work when his mental health declined. (Supplied: Adobe Stock)
His mother was partially paralysed after suffering a stroke a few years earlier and had moved into an assisted living facility, while RL had fallen out with his friends.
As a result, the inquest heard his mental health was in rapid decline in the months before he died.
RL began struggling at school, staying up all night and isolating himself from his father, before making multiple attempts to take his own life.
In her findings, Deputy Coroner Chrissy McConnel concluded that despite the support of teachers, social workers, police and doctors, RL ultimately fell through the cracks of the NT’s mental health system.
In his final months, Ms McConnel found RL had been unable to articulate his feelings, leaving those who knew him questioning “whether anything could have been done to stop him”.
Chrissy McConnel handed down her findings into the death of RL on Friday. (ABC News: Hamish Harty)
A ‘lifetime’ of grief
Suicide is the leading cause of death among Australians aged between 15 and 24, but in the NT, the situation is particularly bleak.
For much of the past 40 years, the NT has maintained the highest per capita suicide rate in the country, and in regional areas like Alice Springs, the numbers are even higher.
In the past five years, the NT has averaged more than 48 deaths by suicide each year, nearly one death a week, including RL’s.
In a statement read to the inquest, his family said they had been “grieving for a lifetime”.
“The sleepless nights and nightmares, the feeling of guilt will never end,”
they said.
In August 2023, the inquest heard RL attempted to take his own life twice, and was admitted to the Alice Springs adult mental health unit as an involuntary inpatient.
The NT has the country’s highest suicide rate per capita and the problem is even worse in regional areas like Alice Springs. (ABC Alice Springs: Xavier Martin)
He described the ward as “scary”, with doctors also acknowledging in their evidence “that an adult facility can be an ‘alarming place’ at times” and may have contributed to RL shutting down emotionally.
But with the NT’s only dedicated youth mental health unit hundreds of kilometres away in Darwin, he would spend almost three weeks there after being diagnosed with a major depressive disorder.
Ms McConnel said it was a situation facing many young people in Central Australia with mental illnesses, whose only option is to share the adult facility.
“I heard evidence that the exposure to adult patients and lack of peers and age-appropriate activities meant the inpatient facility was not an ideal therapeutic environment,” she said.
“The lack of youth specialist-trained staff also means differences in presentation between mental health problems in youths and adults might not be recognised.”
Ultimately, RL was discharged while still considered a high risk of suicide, with one doctor telling the inquest “hospital is not a place where a person can fully recover”.
‘Genuine questions and concerns’
Within weeks, RL was readmitted to the unit after his father raised concerns he was “in serious trouble” but was again discharged after just 24 hours.
His father told the inquest he believed doctors did not fully appreciate the risk his son would harm himself once released.
However, his assessing psychiatrist, referred to as Dr B, testified that while RL’s suicide risk was high, she was “legally obliged” to discharge him as his diagnosis did not meet the criteria for involuntary admission.
It was the view of the psychiatrist who treated 17-year-old RL that he did not meet the criteria to be held in involuntary care. (ABC News: Keane Bourke)
“It was the view of Dr B that RL did not meet the definition of severe disturbance of mood as RL ‘had been engaging in a lot of his … usual activities’ and that RL had fluctuations in mood, rather than pervasively low mood,” Ms McConnel said.
“It is difficult to accept that this was an accurate summation of RL’s recent history.“
Ms McConnel said the mental health team was aware RL had stopped taking antidepressants and that school, which had previously been seen as a protective factor, had finished two weeks earlier.
She noted another psychiatrist testified Dr B’s decision to release RL reflected “a lack of familiarity with symptoms as they present in adolescents”.
“He was viewed through an adult mental health lens,” that psychiatrist told the court.
The deputy coroner made four recommendations for improvement in the youth mental health sector in the NT. (ABC News: Bridget Judd)
Meanwhile, a Child and Youth Team psychiatrist who treated RL before his admission told the inquest she was surprised he was not held longer.
Ms McConnel found the case raised “genuine questions and concerns” about RL’s discharge, but she was unable to conclude either way whether he met the criteria for involuntary admission.
The deputy coroner made four recommendations, including that NT Health update its policies to ensure the Child and Youth Team is consulted before a child is discharged.
“Given the limited confidence that clinicians had in RL’s disclosure of his thinking, and the very limited information on which Dr B based her conclusion that RL was engaging in his usual activities, it is surprising that more substantial steps were not taken to discuss RL’s mood with his father or the school or to obtain further details from RL’s father, St John or the police about the incident that lead to RL’s admission,” she said.
“Despite NT Health staff indicating they spoke with the school and RL’s father about risk, both seemed at different times to be unclear on the message around risk and, incorrectly, perceived RL’s discharge as an indicator that he was not assessed as high risk.”
