Kerrie Carroll died by suicide in 2023. Her partner is pointing the finger at NSW Health

Kerrie Carroll devoted her life to caring for a menagerie of injured, neglected and abandoned animals.
Warning: This story contains discussion of suicide.
At the Lucky Stars Animal Sanctuary, which she founded in the New South Wales Southern Tablelands, Ms Carroll nursed everything from alpacas to wombats and even a bearded dragon back to health.
But when the former nurse needed care from the NSW health system, it failed her.
On October 19, 2023, Ms Carroll was rushed to Queanbeyan Hospital by paramedics after attempting suicide — her second attempt at taking her own life within weeks.
What happened next was a litany of failures in her care, which are outlined in an internal review into her treatment by NSW Health.
Within hours of Kerrie Carroll's suicide attempt, she was discharged from the emergency department, still clutching a bag containing some of the medication she had tried to overdose on.
Just over 36 hours later, she would die by suicide.
Ms Carroll's partner, Clint Seares, said he had concerns about her care in the overstretched emergency department at Queanbeyan Hospital from the start.
"The process felt rushed," he said.
"Kerrie was heavily sedated because of the medication she'd taken. They provided her with a psychological interview, which I didn't really feel was appropriate at the time, as I didn't really feel she was conscious enough to make informed choices."
In the wake of her death, a Serious Adverse Event Review (SAER) by NSW Health found that Ms Carroll was "not fit for interview" when she received a mental health assessment in the emergency department.
The SAER report found "the consumer remained sedated during the mental health assessment".
"The mental health assessment undertaken … was sub-optimal and was not comprehensive, which may have led to her premature discharge."
Despite Ms Carroll's suicide attempts, the assessment "did not include a detailed suicide risk assessment, psychosocial assessment, or management plan".
Mr Seares said he felt the nurse who conducted the interview asked leading questions.
"I was very disappointed and a little bit shocked," he said.
"It was almost like admission to a mental health ward was used as a punishment or a threat, rather than an opportunity for care. It was phrased in terms of 'you don't want to go to this place, do you Kerrie?'" he said.
The review also found that Ms Carroll was discharged without consulting a psychiatrist or senior mental health clinician, despite that issue being raised in a review into another Serious Adverse Event less than two years earlier.
"The team found [Kerrie Carroll] did present with significant safety concerns, which necessitated consultation with a psychiatry medical officer, which did not happen," it said.
Staff at Queanbeyan Hospital also failed to inform Mr Seares when his partner was being discharged.
Instead, he found her on a bench outside the hospital with leftover medication she had overdosed on that had been brought in by the paramedics who had rushed her to hospital.
"I couldn't understand how someone who had tried to commit suicide a few hours earlier was then basically put out onto the bench with the same medication, with a glass of water even."
The SAER found there had been only "minimal staffing" in the emergency department that afternoon because a number of staff had called in sick and Ms Carroll had been released without a proper discharge summary.
The day after her release, the community mental health team assigned to follow up with Ms Carroll made a number of unsuccessful attempts to try to contact her by telephone.
The SAER found that "critically low" staffing levels in the local community mental health team meant a neighbouring regional team had been asked to follow her case up virtually.
By the time that team called an ambulance to conduct a welfare check, it was too late — Ms Carroll had made another attempt at suicide at her home.
This time it proved fatal.
Mr Seares is now taking legal action against NSW Health over Ms Carroll's death, speaking out on the state's troubled mental health system.
Mental Health Minister Rose Jackson said lessons would be learned from Ms Carroll's death.
"Of course my heart absolutely breaks for Kerrie's family; it's a deep tragedy, and obviously we send our sincere condolences, but more than that, a commitment to reflect on the circumstances that led to her death and try to make sure that it never happens again," she said.
Ms Jackson said the Southern NSW Local Health District had implemented the SAER's report's recommendations into Ms Carroll's death, including clarifying the need for a senior mental health clinician to be consulted before patients at serious risk of harm were discharged from the emergency department.
The minister acknowledged many of the issues highlighted in the case were also raised in a recent Four Corners program, where former public psychiatrists described the pressure to discharge mental health patients without proper treatment.
"I could not be clearer in my expectation that everyone receives the highest quality care," she said.
Ms Jackson said NSW, which spends the least per capita in Australia on mental health, was playing catch-up after a decade of underfunding.
"I see it as an urgent priority," she said, hinting to mental health investment in the upcoming 2025-26 NSW budget.
But Mr Seares remains unconvinced, saying many of the cases highlighted by Four Corners bore remarkable similarities to his partner's experience.
"A culture that has an inability to learn is a really scary place to be," he said.
"NSW Health keeps on making the same errors and disastrous results because it's failing to learn. How many more people have to die like Kerrie before they're prepared to do something about it?"

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