Chapter 8 Suicide and Out of Hospital Care

Chapter 8

Suicide and Out of Hospital Care

Chapters 7 & 8 Playlist

8.0 Introduction

According to Griffith University’s Australian Institute for Suicide Research and Prevention, “suicide numbers and rates in Queensland in 2018 recorded 767 suspected suicides by Queensland residents. This decreased from 803 suspected suicides in 2017 … [M]ales represented 77.2% or 592 of these suspected suicides, while females accounted for 22.8% or 175 of suicides [in Queensland]”.^[1] Research supports that more females attend ED than males,^[2] which may mean that more females than males are subject to Emergency Evaluation Authorities (EEAs).

In a ham-fisted and desperate attempt to trade on a COVID-19 good news story, plus I never buy The Australian but there it was serendipitously, 2020 recorded “the lowest annual suicide rate for women since 2013 and the lowest for men since 2016”. ^[3]. To decide whether this really is a good news story, perhaps we need to consider issues in more depth.

8.1 The case of Stuart v Kirkland-Veenstra (2009) 237 CLR 215

I need to be clear from the outset, this case involved police officers, not paramedics. We don’t know how the courts would have responded had it been paramedics not police officers who responded to Mr Veenstra. Police and paramedics are treated differently in relation to duty of care given the legal principles set out in Kent v Griffiths [2000] 2 All ER 474. The facts of Stuart v Kirkland-Veenstra (2009) 237 CLR 215 are at 5.40am on 22 August 1999 Acting Senior Sergeant Stuart and Detective Senior Constable Woolcock observed Ronald Veenstra in a public car park on the Mornington Peninsula. He was sitting in a car; there was a hose connected to the exhaust of the car. The engine was not running. The two officers spoke with Mr Veenstra. Mr Veenstra informed the officers, despite measures he had taken that appeared he had the intention to self-harm, he was in contemplation of suicide. Mr Veenstra told the officers he was experiencing relationship problems and he wanted to go home to discuss his marital problems. He also said he would speak with his doctor. He died later that day in his car, the engine running, and the opposite end of the hose connected to the car’s exhaust pipe was found in the interior of the car with Mr Veenstra.

“Both officers were of the opinion that Mr Veenstra showed no signs of mental illness. He appeared to them to be rational, cooperative and very responsible the entire time. During their conversation he removed the hose from the exhaust and placed it in the vehicle. He did this of his own initiative and not as a result of any suggestion made to him by the officers.

The two officers were aware that they had a power under s 10 of the [Mental Health Act 1986 (Vic)] to apprehend a person who appeared to have a mental illness and to have attempted or to be likely to attempt suicide. They did not exercise that power. They allowed Mr Veenstra to leave the car park. In a patrol log which they wrote up at the end of the shift they recorded that Mr Veenstra was depressed and had contemplated suicide but would seek help and return home. They recorded also that he did not want police intervention and did not want his family informed”.^[4]

The Victorian Court of Appeal held that the police officers owed the deceased a duty of care. The High Court of Australia (HCA) judges overturned this verdict on appeal finding that the police officers did not owe the deceased a duty of care to prevent him from dying from suicide.

An important principle drawn from the HCA ruling is that the courts are prepared to accept that a person who attempts suicide, let alone threaten suicide (but more on that later), is not necessarily by default concomitantly mentally ill. Chief Justice French in Veenstra stated:

“[T]he fact that a person has attempted suicide or prepared to attempt suicide is not of itself sufficient to support an inference that the person is mentally ill”.

As well as identifying that suicidality and mental illness can co-exist, the courts support that the concepts do not necessarily co-exist by default. Furthermore, the decision underpins that people with capacity are to have their autonomy upheld and protected. The facts of this case predate the Victorian Charter of Human Rights and Responsibilities Act 2006 (Vic) although mention is made of the Human Rights Act 1998 (UK) and the right to life. This case fails to take into consideration section 9 of the Victorian Act that states that every person has the right to life and has the right not to be arbitrarily deprived of life. Conflict can be found in state responsibility to prevent suicide, individual autonomy and human rights’ right to life principle. Requisite control of a scene appears to be a threshold the courts are willing to apply in cases where suicidality and self-harm are present. After I introduce the suicide of Kerrie Wooltorton, I will talk specifically to the legal position in Queensland.

8.2 The Suicide of Kerrie Wooltorton

This section is on the death from suicide of Kerrie Wooltorton “who refused treatment after the ingestion of a lethal dose of ethylene glycol”.^[5]

The suicide of Kerrie Wooltorton, to my paramedic legal mind, would not occur in Queensland given the legal landscape in Queensland. The powers given to paramedics in relation to suicide are substantial and this is covered by our next section.

8.3 Suicide and the Law in Queensland

Despite the HCA decision in the Veenstra the law governing police and paramedics responses to suicide in Queensland is dealt with by ss157A-P Public Health Act 2005 (Qld). Section 157B states:

157B Ambulance officer or police officer may detain and transport person

(1) This section applies if an ambulance officer or police officer believes—

(a) a person’s behaviour, including, for example, the way in which the person is communicating, indicates the person is at immediate risk of serious harm; and

Example—

a person is threatening to commit suicide (emphasis added)

(b) the risk appears to be the result of a major disturbance in the person’s mental capacity, whether caused by illness, disability, injury, intoxication or another reason; and

(c) the person appears to require urgent examination, or treatment and care, for the disturbance.

Suicide was decriminalised and repealed from the Criminal Code 1899 (Qld) by s 4 of the Criminal Law Amendment Act 1979 (Qld). The decriminalisation of suicide did not confer a right of suicide in Queensland. It remains an offence, according to s311 Criminal Code Act 1899 (Qld). It is an offence to:

(a) procures another to kill himself or herself; or

(b) counsels another to kill himself or herself and thereby induces the other person to do so; or

(c) aids another in killing himself or herself.

Before we discuss this in more detail, we need to remember that all individual’s above the age of 18 have capacity unless proven otherwise. The test for capacity in Queensland can be found here, here and here. If it is doubted whether a person is capacitous, but an individual can demonstrate they are capable of understanding the nature and effect of decisions about [a] matter; and freely and voluntarily making decisions about [a] matter; and communicating the decisions [about a matter] in some way, the principles of autonomy and right to self-preservation ought to prevail. I encourage you to read this in conjunction with section 16 Human Rights Act 2019 (Qld) – every person has the right to life and has the right not to be arbitrarily deprived of life and section 29(1) Human Rights Act 2019 (Qld) – every person has the right to liberty and security. The breadth of s157B Public Health Act 2005 (Qld) provisions have not been tested for compatibility with the Human Rights Act 2019 (Qld). If they are, it would be my best guess to say that the basis for an involuntary admission to hospital under an Emergency Evaluation Authority (EEA) will remain, but some of the s157B language may need to be tightened up to ensure a fit with the Human Rights Act 2019 (Qld). Time will tell. I’m a little worried I may be the only person in Queensland with an interest in s157B Public Health Act 2005 (Qld). It can be lonely having niche interests.

Looking at s157B Public Health Act 2005 (Qld) in more detail. You know you want to know more. You’ve read this far, haven’t you? Before we get onto the example the legislation provides, let’s consider the nature and the purpose of s157B Public Health Act 2005 (Qld). Police and paramedics are entitled to detain and transport a person under an Emergency Examination Authority (EEA) (s157D Public Health Act 2005 (Qld)), with force (s157L Public Health Act 2005 (Qld)) if the force is considered necessary and reasonable in the circumstances, and if the person is:

• at immediate risk of serious harm
• the risk appears to be the result of a major disturbance in the person’s mental capacity
• the major disturbance in the person’s mental capacity can be caused by
  • illness
  • disability
  • injury
  • intoxication
  • another reason
• requires urgent examination for the disturbance
• treatment and care for the disturbance
• at imminent risk of injury

Up until now I have only ever talked of people possessing or lacking capacity. Never have I mentioned disturbance in a person’s mental capacity. The law is clear on capacity, people either have it or they don’t. Disturbance is brand new to me. What in the name of the Honourable Catherine Holmes does this mean? Is it another way of describing mental disorder? I am suspicious of the language used in this section. And that’s even before we get to the example the section offers readers. I think the language is disingenuous and fails to conform with legal convention on mental health and mental capacity. I suspect that using novel language distinct from mental illness, mental capacity and mental disorder permits a much broader application of an EEA based on risk. Could this section be creating an additional method to justify the treatment of patient without their consent. Not so much mental illness, not so much lacking capacity but disturbed capacity. What does this mean I hear the collective cry of over 200 hundred CSB338 students? Okay, maybe not cry. I may have over egged the pudding with that previous but one sentence. A good place to look for definitions is in an Act’s dictionary. Here you go, I’ll make it easy for you. Click here and look for the Public Health Act 2005 (Qld)’s definition of disturbance and capacity. Can’t find it, can you? It’s because neither of these two words are defined in the Public Health Act 2005 (Qld). Unfortunately, I can’t help you. I can define a mental illness in Queensland for you. I can define mental capacity in Queensland for you. But I have no idea the legal definition of disturbance in capacity. (Of course I do, I’m being melodramatic.)

Following then onto the example provided in s157B Public Health Act 2005 (Qld) of a person threatening to [I won’t adopt the language of the Act and use the ‘c’ word as it has unhelpful connotation and I’m happy to address this in a moment] suicide can be detained by paramedics using force if necessary. This means any person making an expression of exasperation that bears resemblance to a suicide threat will be detained under the provisions of an EEA in Queensland. A person need not have attempted suicide. A threat is enough to justify detention and transport. Hang on, what about the HCA decision in Veenstra? Good question, what about it? To my eyes it looks like whoever drafted s157B Public Health Act 2005 (Qld) decided not to follow it and veto risk of any chance of a similar event occurring in Queensland.

Don’t misconstrue what I’m saying. I want paramedics to prevent suicide. I want us to help drive down suicides in Queensland. I just want us to do it in a way that maintains a therapeutic alliance with patients without adopting a disproportionate and heavy handed approach to preventing suicide. I must also add, I am not opposed to the application of EEAs. What I do hope for is paramedics to think about what they are trying to achieve and if the measure proposed to achieve an outcome is proportionate to the measures used to achieve that outcome. Loss of liberty has impact. Irrespective its duration. Depriving an individual of their liberty needs to be measured carefully against the immediate risk of serious harm and such a decision needs to be assessed for compatibility with s29 Human Rights Act 2019 (Qld).

Before we head to the case study, I just want to make mention of another ‘c’ word to avoid. This ‘c’ word relates to suicide. The ‘c’ word is commit. Anyone with an interest in suicide prevention is taught that language is critical. Here is an excellent resource on preferred language when discussing suicide, including problematic words to avoid:

https://mindframe.org.au/suicide/communicating-about-suicide

https://mindframe.org.au/suicide/communicating-about-suicide/language

Suicidality is not an uncommon feature of paramedic practice. Combinations of threats, attempts and deaths from suicide feature in emergency care. I am aware fully the case of Veenstra had a tragic outcome. I also believe that the detention of individuals based on threatening suicide does not address suicide prevention in the community. I worry that it could damage the relationship paramedics have with their patients. The way forward in suicide prevention must incorporate a human rights approach that upholds where possible patient autonomy. Additionally, language incorporated into legislation must conform to accepted conventions thus ensuring predictability and clarity in the space of involuntary detention and transport for threatened suicide.

It seems a little late in the chapter to bring this up, but I hope I have not impacted anyone given the nature of this chapter. To restate, suicide is a feature of paramedic care. It’s important you understand the legal landscape in relation to this area of your work. Not at the expense of your own wellbeing, however. What follows next isn’t better. I hope everyone understands the importance of this subject in relation to practice. Professionally I think there is a lot more to be done in terms of suicide prevention. Hopefully, I can find out more from you in tutorials.

8.4 Case Study

*Please be advised this case study contains reference to domestic violence*

“That’s three welfare checks, now. How many times do I have to tell comms that we are delayed on scene, and we will either call clear or transport as soon as possible?” Amy huffed. “Is she going to come with us, anyway?

“I don’t know. She’s upstairs with the three girls. She said she was going to chat to her kids for a few minutes but that was over 20 minutes ago. I think she was waiting for the cops to leave.” Bridget explains.

Bridget walks back upstairs to reassess their patient, Cathy. Bridget enters Cathy’s bedroom. Cathy is sitting on the bed. Her face in her hands. Her chest and shoulders heaving in time with her sobs. Her three girls, all under 8 years of age, lying rigidly on the bed behind their mother. Bridget looks to the girls and offers a sympathetic pursed lip smile but gets nothing in return. Not even from the youngest child.

“Cathy, are you sure he didn’t hit you? Can you let me examine you? I need to make sure you’re not injured?” Bridget pleaded. “Look, he’s not coming back. The police have him. You’re safe now. I promise.”

Thankfully Derek hadn’t made it upstairs. Cathy and the girls had escaped upstairs and barricaded themselves into the bedroom. The downstairs was another story. It was like a storm cell had swept through the downstairs living area. Barely a single item remained on shelves or walls. The TV shattered into tiny pieces. Derek’s fists had acted like pile drivers and there were more holes than there was wall. The inside furniture was outside, and the outside furniture was inside. All the glass doors to the patio were smashed, blinds torn from their fixings. The only things left untouched, either by design or accident was a picture of three men holding up three threadfins in each of their right hands and beers in their left. A symbol of an ichthys remains on the wall.

“Cathy, we’re here to help. Let us help you.” Bridget moves towards Cathy, she winces and pulls away.

Amy appears at the door of the bedroom and asks Bridget to join her in the hallway.

“I found these in her handbag.”

Amy puts the handbag on the ground and begins to take out packet after packet of unopened medication and hands each to Bridget. Bridget looks at the labels. Effexor, Serepax, Inderal, Endep, Endone and Subutex. Lots of Subutex. None of them have Cathy’s name written on them. None of them have any names on them. Amy stares at Bridget. Bridget sighs and leaves Amy in the hallway and walks back into the bedroom.

“Cathy, are these yours?”

Silence.

“Cathy, I need to know.” Bridget said urgently.

Cathy peers above her hands to see what Bridget is holding. She shakes her head.

“Cathy, what are you planning to do with these? Are they yours? I know you’ve been through a huge amount, but I need to know more about these medications Amy found in your handbag.” Amy walks into the bedroom and stands next to Bridget.

Cathy glares at Amy incensed. “Who gave you permission to look through my handbag?” Cathy attempts to stand but stumbles and sits back down on her bed.

“You’re a right pair of bitches, aren’t you?”

“Cathy, your children. Don’t talk like that.”

“Talk like what? Like a woman who has been taken to the brink by a coercive and controlling bastard for 13 years. Piss off, the pair of you. Neither of you look old enough to be out without a chaperone. They’ll give anyone a uniform in this State. It’s a joke is what it is and you two are the punchline.” Cathy bellows.

“I know it might not seem like it, but we are trying to help you,” Amy pleads, “if you are thinking of doing something st—” Bridget cuts Amy off.

“Stop, let’s all take a moment,” Bridget interjects, “after finding the medication, we are worried you are at risk of immediate harm. We don’t know if you plan to take it or what your thoughts are in relation to the medication but there is enough information here for us to detain you under an emergency evaluation authority and transport you to a place of care. We do not require your consent and if you refuse to come, we are entitled to use force we consider necessary and reasonable in the circumstances.”

Amy continues, “The medication in your possession is not for therapeutic purposes. If taken cumulatively it will end your life, your children will lose their mother. The risk you pose to them and to yourself, Cathy permits us out of necessity and based on the information we have obtained since on being on scene for over an hour to get you to help even if we have to pick you up and carry you to the ambulance.”

“What about my girls? Who will look after them? I’m not leaving my girls. Their grandfather could come, or Derek’s brother. They’re just as bad. I’m not leaving my girls. Who will protect them?”

Amy and Bridget look at each other and simultaneously make one step forward towards Cathy…

Now you decide what should happen next.

8.5 Podcast

Suicide and Out of Hospital Care with Katrine Del Villar

8.6 Further reading

Moritz, Dominique (ed), Paramedic Law and Regulation in Australia (Thomson Reuters (Professional) Australia, 2019) pp 38-42

8.7 Optional reading

Callaghan, S., Ryan, C., & Kerridge, I. (2013). Risk of suicide is insufficient warrant for coercive treatment for mental illness. International Journal of Law and Psychiatry, 36, 374-385.

Craigie, J., & Richardson, G. (2013). Mental capacity in the shadow of suicide: What can the law do? International Journal of Law in Context, 9, 87-105.

Goldman-Mellor, S., Olfson, M., Lidon-Moyano, C., & Schoenbaum, M. (2019). Association of Suicide and Other Mortality with Emergency Department Presentation. JAMA Network Open, 2, e1917571-e1917571.

Griffin, E., Kavalidou, K., Bonner, B., O’Hagan, D., & Corcoran, P. (2020). Risk of repetition and subsequent self-harm following presentation to hospital with suicidal ideation: A longitudinal registry study. EClinicalMedicine, 23.

Nordby, H. (2013). Should paramedics ever accept patients’ refusal of treatment or further assessment? BMC Medical Ethics, 14, 44.

Rees, N., Rapport, F., & Snooks, H. (2015). Perceptions of paramedics and emergency staff about the care they provide to people who self-harm: Constructivist metasynthesis of the qualitative literature. Journal of Psychosomatic Research, 78, 529-535.

Ryan, C. J., & Callaghan, S. (2010). Legal and ethical aspects of refusing medcial treatment after a suicide attempt: the Wooltorton case in the Australian context. Med J Aust, 193, 239-242.