Katarina and Jurgen

Jurgen was ‘a citizen advocate’ for Katarina, who had an acquired brain injury and psychosocial disability.

Jurgen told the Royal Commission that before he met her, Katarina had engaged with psychiatric facilities, police services, organisations for victims of crime, housing services, public guardian and trustee services and disability service providers. He said all these services were aware of her disability, but did not keep her safe or support her to use services developed for people with disability.

Katarina’s mother had approached the advocacy service he worked for in the early 2020s. The agency deemed Katarina as the ‘number one most vulnerable person’ on its books, and her mother was ‘in a state of desperation’.

For about a decade, Katarina had been under an involuntary treatment order. She was ‘predominantly being treated by very long psychoactive drugs and psycho epileptics’ at dosages that were ‘impairing her cognition and decision-making functions and capacities’.

Katarina had ‘a long, long history’ of taking off interstate to see various family members when she was ‘becoming unwell’. Her mental health team knew of this, but ‘never actively intervened to prevent her from going’.

‘Nor would they ever follow-up when they found out, for example, that she didn’t turn up for a deposit injection. So that would trigger in any system a phone call at least or a community visit … [But] they were so detached … [She] would invariably end up being hospitalised or put into a prison cell because she was psychotic.’

Jurgen said health systems in both states failed to communicate with each other in a ‘safeguarding capacity’ and Katarina’s condition ‘was obviously deteriorating further and further’.

One treating psychiatrist ‘had labelled’ her as ‘a lost cause’.

‘And her story is really one where she was desperately trying to reach out on multiple occasions to professionals to help her. And in the end, her deterioration had set in on such a profound level that to bring her back was really difficult. And this was evidenced by her more frequent cyclical hospitalisations.’

Katarina’s mother was constantly ‘trying to engage’ with mental health teams, but ‘they just labelled her a neurotic’.

Several months before her death, Katarina had left her home state and was ‘doing really badly’. Jurgen arranged for a clinical team from one of the hospitals she was known to to assess her, ‘but they deemed her okay’.

‘It beggared belief, it was obvious she was psychotic. You don't have to be a psychiatrist to know that.’

Jurgen was trying to get Katarina on a plane back home, where she would at least have the support of him, as her advocate, and her mother. But he said services in both states ‘then became intentionally obstructionist’. They refused to recognise him as ‘an independent citizen advocate’.

‘That meant nothing to them. And as a result, they wouldn't engage with me, and that's why I had to become a nominated support person.’

Even then, Jurgen said, it was ‘clear they didn’t want to cooperate’.

Jurgen said the hospital left Katarina ‘wandering around floridly psychotic’. At a train station, two police officers realised she was ‘acutely unwell’ and took her to an emergency department.

After a lengthy period at the hospital, Katrina finally returned to her home state. The COVID-19 pandemic had begun.

’Her clinical team wanted to put her into hotel accommodation rather than hospitalise her,’ Jurgen said. ‘And I thought to myself, you have got to be kidding me.’

The cause of Katarina’s death, at the age of 40, has not been determined. Jurgen believes it was ‘preventable’ and that a lack of care by health workers ‘contributed’.

He feels Katarina ‘needed a friend … for someone with her consent to step in as a full guardian’.

‘Because she had been so damaged by this dangerously disorganised state-based mental health systems across two states over 20 years that … it absolutely destroyed whatever remaining capacity she had because of the way that she fell through these jurisdictional cracks.’

Jurgen would like to see legislative changes to bring equitable balance in mental health by allowing people with disability to be supported by an advocate.