Like the boy in her story, Perth artist Melanie had the 'worry monsters' before her death
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Her frustration was later compounded when it was revealed she didn’t live inside the Fremantle Hospital catchment and would need to be referred to a clinic within her area.
At this point Ms Tregonning said she had plans to go to a comedy show with her parents and, following an informal assessment, it was determined she could go home.
‘Systematic failures’
Ms Tregonning didn’t go out with her parents to the show as she had planned and at 9.30pm, told her parents she planned to sleep in her studio.
About 7.30am the next day, Ms Tregonning’s father found her dead.
“The accounts given by the doctors and nurse involved in Ms Tregonning’s case on the night reveal there were failures in communication, both on a systemic level and between individuals,” Ms Linton said.
“At the time they gave their evidence at the inquest they all acknowledged that there was critical information that had not been before them on the night, and which might have altered the course of events.”
From Small Things.Credit:Curtin University
Ms Linton made several recommendations in the wake of Ms Tregonning’s death – the very least, that there had been a breakdown in communication between hospital staff and on a systemic level which needed to be addressed.
She also recommended a mental health observation area be commissioned at Fiona Stanley Hospital Emergency Department.
The coroner also indicated she would also likely make an adverse finding against a doctor involved in the case, who she said had “sufficient information” to raise a red flag about Ms Tregonning’s treatment.
“In the 48 hours leading up to her death Ms Tregonning sought help from several different health professionals,” Ms Linton said.
“Unfortunately, due to a series of miscommunications, system problems and inadequate assessment, she did not receive the help she needed.”
Small Things
Following Ms Tregonning’s death, her family published her graphic novel Small Things with the help of acclaimed Perth artist and writer Shaun Tan.
Through illustration, Small Things tells the story of a little boy who struggles with feelings of isolation, anxiety and depression.
In her drawings, Ms Tregonning depicted the feelings as monsters that shadowed the little boy and appeared in his dreams.
It was listed as one of WA’s most significant books of 2016.
“Like the boy in her story, Ms Tregonning became overwhelmed with anxiety and depression. Sadly for Ms Tregonning, when she needed help most, she did not receive it,” Ms Linton said.
Ms Tregonning’s family are now staunch mental health advocates.
If you or someone you know needs support call Lifeline 13 11 14, or Beyond Blue 1300 22 4636. Please reach out.
Article source: https://www.smh.com.au/world/north-america/enough-is-enough-it-s-time-for-mueller-to-bring-out-the-big-guns-20180810-p4zwue.html?ref=rss&utm_medium=rss&utm_source=rss_world
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