The family of Gabriella Kathleen Ann Freeland, known as Kate, was unaware of her suicide attempt a week prior to her death after being granted leave from Palmerston North Hospital’s mental health inpatient unit. Kate, 28, died on Christmas Eve 2021 at her Auckland home, a day after her father picked her up from the hospital.
Coroner Finds Decision to Grant Leave Unwise
Coroner Janet Anderson described the decision to allow Kate leave as “unwise” and expressed concerns about the information provided to her father, Robert Freeland. She noted that he was not fully informed of the seriousness of Kate’s condition or the potential risk to her life during leave.
Family Calls for Mental Health Reform
Kate’s brother, Jared Freeland, who discovered her body, called for her death to prompt improvements in mental health services. He described her case as indicative of the “parlous state of mental health services” in New Zealand, which he termed a “national disgrace.”
Medical History and Decline in Mental Health
Kate was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) as a child and treated with Ritalin. She completed a computer science degree but experienced a severe decline in mental health after her mother’s death from motor neurone disease in 2017. Following this, she developed heavy alcohol use and increasingly erratic behavior.
From mid-2020, Kate sought medical attention for symptoms related to anxiety and feared alcohol-related liver damage. She went missing in August 2020 and was later found living itinerantly. Despite expressing suicidal thoughts and possessing items capable of self-harm, she was initially discharged after declining treatment under the Mental Health Act.
Hospital Admission and Diagnosis Controversy
Kate was admitted to Palmerston North Hospital after a police incident involving “train hopping” in 2021. She was assessed as psychotic with schizophrenia by multiple clinicians and placed under compulsory treatment. She later disputed the schizophrenia diagnosis, and her psychiatrist indicated she likely had ADHD alongside depression and a personality disorder.
Events Leading to Death
Despite a serious suicide attempt on 18 December 2021, Kate was readmitted, deemed stable, and allowed leave to spend Christmas with family. Her father was reportedly unaware of the recent attempt or the full extent of her risk. She returned home on 23 December, enjoying family activities, but was found dead hours later in her room.
Clinical and Systemic Concerns
The MidCentral District Health Board’s independent review highlighted that Kate downplayed her risk, which was not adequately accounted for. Staff expressed uncertainty about whether her father was fully informed of her condition. Recommendations included improved assessment, treatment planning, leave protocols, discharge procedures, and communication with families.
Health NZ Introduces New Protocols
Health NZ has updated policies for leave, discharge planning, documentation, and family communication. The coroner emphasized further action, recommending independent review of the inpatient unit’s culture, reassessment of staffing, and ongoing audits to ensure compliance with new protocols.
Coroner’s Recommendations
Coroner Anderson noted the dangers of hindsight bias but concluded that granting leave soon after a serious suicide attempt and a change in diagnosis was unwise. She recommended enhanced family communication, staff training, and improved oversight to prevent similar tragedies.
Continued Impact on Clinical Team
The treating team remains affected by Kate’s death. Psychiatrists highlighted the challenges of managing high-risk patients in near-capacity inpatient services. Despite careful assessment and planning, the tragic outcome underscores the complexity of mental health care and the need for ongoing systemic improvements.
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