Coroner deemed Yorta Yorta man’s death “Preventable”

Jun 2, 2023

WARNING: VACCHO advises Aboriginal and Torres Strait Islander people that the following article contains references to mental health, suicide, and those who have returned to the Dreaming.

VACCHO is deeply saddened to learn that the death of Yorta Yorta man Mathew Luttrell, 43, could have been prevented had he received appropriate culturally-led and culturally-safe mental health care.

Mr Luttrell was voluntarily admitted to Mildura hospital following a suicide attempt on 11 November 2018. Hours after he was discharged the following day, Mr Luttrell died by suicide.

Coroner Audrey Jamieson expressed that several chances to intervene were overlooked and believed Mr. Luttrell’s death could have been avoided. According to Ms. Jamieson’s findings, the hospital neglected to offer Mr. Luttrell care and treatment that aligned with his cultural needs. Furthermore, they failed to provide culturally-appropriate options for follow-up care or support upon his discharge following his visit to the hospital on 11 November 2018.

Download the Coroners Report here

VACCHO CEO, Jill Gallagher AO, was disheartened to hear the healthcare system failed Mr. Luttrell.

“The findings of the Coroner’s report into the passing of Mr. Luttrell is devasting to say the least. My sincerest thoughts and condolences go out to Mr. Luttrell’s family,” Ms. Gallagher said.

“Health service providers need to take the time to meaningfully listen to the needs and experiences of Aboriginal communities,” Ms. Gallagher stated. “We have the solutions for creating a culturally-safe, sustainable, self-determining mental health system.”

VACCHO encourages Aboriginal and Torres Strait Islanders to know their rights when it comes to healthcare to ensure that Mob are treated with the respect, dignity and understanding they deserve.

The “You and your Mob have healthcare rights” campaign resources, adapted from the Australian Charter of Healthcare Rights, is currently being rolled out to all public and private hospitals, day procedure services, general practices, community health services and Aboriginal Community Controlled Health Organisations (ACCOs).

The resources highlight Access, Safety, Respect, Partnership and Information as key pillars to knowing your healthcare rights and receiving the treatment you need to get well.

Download the resource here

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VACCHO is the peak body for Aboriginal and Torres Strait Islander health and wellbeing in Victoria – the only one of its kind – with 33 Aboriginal Community Controlled Organisations as Members. VACCHO Members support over 65,000 Aboriginal and Torres Strait Islander people in Victoria, and combined are the largest employers of Aboriginal people in the state.