Carley Metcalfe, 40, was found dead in the river near Mullumbimby on November 27, 2017.
Carley Metcalfe, 40, was found dead in the river near Mullumbimby on November 27, 2017.

Parents’ pain: Inquest hears Carley fell through the cracks

A suite of possible recommendations have been proposed following the inquest into the death of Northern Rivers woman Carley Metcalfe.

An inquest into the circumstances surrounding the 41-year-old's disappearance and death in November, 2017 began last year but was put on hold because of COVID-19 concerns.

It continued before the Coroner's Court in Lismore and Byron this week.

Counsel assisting the coroner, Kirsten Edwards, began her submissions by acknowledging the "dignity" of Ms Metcalfe's parents, Chris and Max, during the "painful and fragmented" inquest process.

"They've had to hear about their daughter falling through the cracks like paperwork," Ms Edwards said.

She noted Ms Metcalfe was at one point described as posing a "conundrum" to clinicians.
"But she wasn't a conundrum, she needed care," Ms Edwards said.

The inquest heard Ms Metcalfe had battled with some substance use but was on an "upwards trajectory" for a long period.

She had stopped taking medication, including a common antipsychotic drug, the inquest heard.

Ms Edwards asked the coroner to find there should be improved "integration of mental health records" between different organisations and health departments.

Ms Edwards said there was not sufficient evidence to be sure of Ms Metcalfe's cause of death.

While she was reported missing on November 3 after her belongings were found in Mullumbimby, Ms Edwards said some weight should be given to reports of sightings of Ms Metcalfe in the same town the week of November 22, 2017.
"Because the manner and cause of death is unknown … it's hard to know if different treatment at the hospital could have altered the outcome," Ms Edwards said.

"It is hard to say if Carley would have been detained under the Mental Health Act during the time of her death."

She said the coroner should find no causal link between Ms Metcalfe's time in hospital and her death.

She said they could, however, identify "missed opportunities to help Carley and to alter what had been an upwards trajectory and was starting to move down".

Ms Edwards asked State Coroner Teresa O'Sullivan to find Ms Metcalfe was experiencing "psychotic behaviour for some days prior" to her hospital presentation.

She also asked Ms O'Sullivan to find "Carley was not … acutely intoxicated on November 1 2017".

This is significant, as the decision not to admit Ms Metcalfe into the Lismore Base Hospital mental health unit that night was based on a psychiatric registrar's perception she was intoxicated.

Although he asked for a test to confirm this - or rule intoxication out - this was never conducted.

The registrar's advice Ms Metcalfe was "acutely intoxicated" led to his psychiatric consultant's belief she could not be admitted to their ward at that stage.

The inquest information about Ms Metcalfe's schizophrenia diagnosis was not before the registrar at that time.

Ms O'Sullivan is expected to hand down her findings on June 30.

A suite of draft recommendations have been put before her for consideration.



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