Warning: This article contains references to mental health and suicide.
Angelica Johnson took her own life within days of being released from a public psychiatric unit, triggering accusations she was "abandoned" by the Queensland health system.
The decision to discharge her from the Royal Brisbane and Women's Hospital (RBWH) came three months after she was severely injured in an earlier suicide attempt on the grounds of the Caboolture Hospital, north of Brisbane.
Her devastated family members were unaware she had even left the RBWH unit when they were told the much loved 41-year-old's body was found on a beach, north of Brisbane, in May this year.
The family says the RBWH failed to contact a friend Angelica claimed she was going to live with, and support her, after her release.
Angelica's grieving brother Matt Johnson says the friend had not heard from her in months, and was unaware she was even in hospital.
"Staff didn't verify anything," he says.
"No one was told, no one was contacted. Speaking to her on the phone a few times a week, she wasn't well, she was upset, she was crying constantly. I don't know how she could have appeared to be someone that was well enough to look after themself.
"I feel that she didn't get anywhere near what she needed."
With the Queensland election less than five weeks away, the case highlights the severe stress plaguing the state's public mental health services.
In a pre-election pitch, Queensland branch chair of the Royal Australian and New Zealand College of Psychiatrists Brett Emmerson has called for 350 new mental health beds, 2,000 extra community mental health workers and a funding boost of $300 million a year.
That's over and above the almost $500 million Treasury estimates it will have raked in the last financial year from the Labor Government's Mental Health Levy, paid for by big business.
"We often have to discharge people prematurely because there are sicker people waiting in the emergency department for their beds," Professor Emmerson says.
"Our community-based mental health services are not adequately staffed. We have skeleton staff into the evenings and at weekends.
"We need our community mental health services to be functioning seven days a week with significant numbers of staff on. The whole system is not designed for good care."
No effort made to ensure safe accommodation
Angelica's previous suicide attempt happened inside the Caboolture Hospital grounds after she discharged herself from that facility's mental health ward in February.
For the next three months, she was treated for a ruptured kidney and multiple fractures to her pelvis and hand at the RBWH where she was placed on an order authorising involuntary inpatient care for mental illness.
But on May 17, she was released after the treatment authority was amended from inpatient care to treatment in the community. Her family says the hospital made no attempt to substantiate where she planned to live. Her body was found three days later.
Mr Johnson says the family feels the sister they affectionately called Angie, who bore deep scars from a traumatic childhood, was "abandoned by the health system and we were powerless to stop it".
He says his "very loving and caring" older sister, was discharged on a Friday afternoon when "the services she's supposed to be referred to don't operate for another two-and-a-half days".
"The Friday discharge, it's not good for anyone, let alone someone at high risk," Mr Johnson says.
"Verifying the support that someone has … actually checking, just making the phone call, making the contact, any kind of follow up could have saved this from happening."
When she was well, her siblings remember her as beautiful, kind and a jokester who revelled in making people laugh and "forever quoting movies".
"She always brightened the room," Mr Johnson says.
"She always wanted to make sure everyone was looked after, entertaining the kids, putting on silly voices.
"We just loved being around her."
Loading...
But she battled severe mental illness for years.
In response to extensive questions about Angie's care, Metro North Health, which takes in both the RBWH and Caboolture Hospital, extended its condolences to the Johnson family.
"As with any unexpected death, a thorough review into the care provided to this patient and the circumstances surrounding her death has been undertaken," Metro North's mental health executive director Dr Kathryn Turner says in a statement.
"These findings have been collated to be shared with the family through an open disclosure process. A date for this has been set.
"Metro North Health continues to liaise with the family and the open disclosure process provides the opportunity to talk about the review findings."
'You wouldn't put a dog in there'
Professor Emmerson says Greater Brisbane's public mental health units are "not fit for purpose".
"The inpatient units at the Princess Alexandra, the Royal Brisbane, Prince Charles and then single wards at Logan and Caboolture were all built back in the 1990s and it's impossible to provide contemporary mental health care in 30-year-old wards that have never had any refurbishment apart from a coat of paint," he says.
"The families that I see … want to be in contemporary mental health facilities. These are single rooms with an ensuite.
"At Royal Brisbane, for example, there are still four-bedded bays where four people share a single toilet."
Ex-police officer and former Queensland Health inpatient advocate Anne Garton has lived with severe mental illness for more than half her life, spending long stretches of time in Brisbane's aging mental health facilities, including the RBWH.
"I spent a lot of time as a patient in their psychiatric emergency centre. You wouldn't put a dog in there," she says.
"It was terrifying, it was unsafe.
"The public system is so underfunded, so dysfunctional, totally inadequate. Staff are doing the best they can with nothing. I mean, less than nothing."
But Ms Garton hasn't needed a hospital stay in more than three years, something she credits stable housing, a dedicated psychologist, her lifelong love of exercise and support through the National Disability Insurance Scheme (NDIS).
"If I maintain my current supports, I doubt I would ever return because I've learnt how to manage my symptoms, I've just learnt the skills," the 48-year-old says.
"I understand how my inner world works now, thanks to my psychologist. He's taught me all the skills to manage in my personal world … all the deficits that I really struggled with that stopped me from having friends, stopped me from having relationships, stopped me from socialising – all the sorts of things that most people do and take for granted."
Angie Johnson's death "hangs heavily" on her five siblings.
"We feel like it's our fault that she got to the stage she was at even though we did everything we could," her brother says.
Angie used to tell them if she could do anything, and money wasn't an issue, she would open a dog refuge.
The beach where she died is well-known as dog friendly and a good place to watch sunrises.
After her death, they scattered her ashes there.