Ashley believed she had one last shot to get help. Like millions of Australians every year, she looked for it in a hospital emergency department.
Myree Webb was in the middle of settling the sale of the family home when she got her daughter's text.
They had just moved into a new house east of Perth, set with a sweeping verandah and bushland vistas.
Her adult daughter Ashley was living with her during a rough patch after losing her baby to stillbirth.
Myree hoped the bushland setting would bring her daughter some peace.
Ashley was experiencing pins and needles, muscle weakness, burning and numbness, and was racked with whole-body twitches and trembling which would wake her during the night.
But most worrying to her mother, Ashley sometimes described feeling like her brain was "on fire".
In November last year, her pain was so acute the 31-year-old sought urgent care.
She texted her mother that she was at the Midland Hospital Emergency Department trying to get help.
Ashley told her she wanted an MRI because she believed that would reveal the cause of her pain.
Ashley
I’m going to lie and say I was unconscious … a week ago, so they will scan my brain. I can't keep living like this.
6:58PM November 12
Ashley
This is my last chance of going to hospital, isn't it?
10:03AM November 13
This was not Ashley's first time seeking help in Midland Hospital, a new public facility run by private contractors St John of God.
Her mother believes by November 2022 she had been to the ED at least five times.
Along with her physical pain, Ashley was experiencing poor mental health and had been taken to hospital by ambulance multiple times.
Her mother said she had attempted suicide, and in July, was admitted to a psychiatric ward for two weeks.
"She just went downhill really fast," Myree said.
"We were just on this hamster wheel of the three — the hospital, GP [and] Midland community mental health.
"And none of those seem to be of any benefit to her."
Her last hospital visit
Myree can't stop looking back at the dozens of text messages she exchanged with Ashley while she was in hospital in November.
Ashley
They want to admit me to mental health but I am so f***in sick. Please tell them when they call you Mum, it's not mental health, it's brain damage.
1:32PM November 13
Ashley
They found [self-harm] stuff in my bag from when I collected them, but told them I tried [taking my life] again yesterday so they will scan.
1:32PM November 13
Ashley
I shouldn't be sent to the psyche ward sick, I can't even taste food.
1:46PM November 13
Mum
Not necessarily. Just stop freaking out and go with the program.
1:50PM November 13
Ashley
I need help, not to be shoved in a psyche ward
1:50PM November 13
Some hours after these texts, a staff member called Myree.
"[They] said, 'I don't know what to do with her'," Myree said.
"And I said, 'Excuse me?', and they said, 'She's being quite belligerent and difficult'.
"I told [them], 'She's desperate'."
Frantic texts reveal complex medical history
Ashley had struggled with postnatal depression in the past.
After her second child was born, she was also diagnosed with functional neurological disorder (FND).
It's a complex condition that affects the parts of the brain that control movement and can cause pain and muscle weakness.
It's difficult for clinicians to diagnose and measure because it presents symptoms that are similar to other neurological disorders.
Ashley carried a note with her to medical appointments describing her symptoms to make sure she remembered to list them all.
"It's really just heartbreaking to have seen her in pain for so long and I couldn't do anything about it," Myree said.
"I tried to advocate for her and speak so many times.
"I would see her trembling, her legs would shake.
"She'd be like someone with Parkinson's disease, her body trembled."
The next day
On November 14, the hospital called her parents. Myree said they told her Ashley would be discharged.
Mum
They are trying to get you out of there. Dad was angry and went right off at the doctor.
12:05PM November 14
Ashley
So what's going to happen then?
12:07PM November 14
Mum
Not sure. They are going to talk to you again. But so far everything they test has come back normal. Dad doesn't want to keep going through this.
12:10PM November 14
Mum
He went ballistic at them on the phone, I really mean it. He doesn't want them to release you to us again.
12:10PM November 14
Ashley
Does dad not believe me? Or is he done with them not helping?
12:17PM November 14
Mum
He is annoyed by the same thing happening over and over ... we are just regular people who have no support.
12:17PM November 14
Myree said a staff member called her again and said Ashley would be discharged and needed to go to a community mental health service.
She said she told the hospital on the phone that her daughter would die.
Her husband grabbed the phone and told them they were "signing her death warrant".
Mum
They want to release you no matter what.
12:23PM November 14
Ashley
I don't want to be!
12:23PM November 14
Ashley
They are kicking me out to go in the waiting room.
12:52PM November 14
Ashley did not return to hospital after that.
Less than three weeks later, she took her own life.
Ashley's mother said when she was discharged, the hospital gave her back her bag which contained self-harm implements.
"We as her parents begged them not to release her," Myree said.
"How can there not be a process where if someone presents to an ED and admits they've tried to commit suicide, they've got the article in their bag?
"Should there not be some kind of protocol there where they're not released?"
Questions left unanswered
Myree sought a copy of Ashley's medical records to try to verify what her daughter told her in her texts — that she'd told hospital staff she'd attempted suicide and had self-harm implements in her bag.
But the hospital told Myree that because she was not the executor of Ashley's will they would not release her medical records to her due to privacy restrictions.
For the same reason, the ABC was unable to independently verify what transpired in the ED beyond what Ashley said in her texts.
The WA Health Minister's office told Ashley's family it would escalate the matter to the Department of Health, which has overarching responsibility for the hospital, for "urgent attention and investigation".
In a statement, St John of God Midland Public Hospital confirmed a patient attended the emergency department and said they received "appropriate care".
"The hospital has commenced a thorough internal review," the statement said.
"The initial recommendations do not suggest that any changes to existing processes or policies are required.
"On behalf of the hospital, we offer our heartfelt sympathy to the patient's family for their loss."
More people seeking help for mental health in EDs
Ashley was just one of about 300,000 mental health patients accessing emergency care around the country each year.
In 2020-2021, this represented about 3.5 per cent of all presentations, according to data from the Australian Institute of Health and Welfare.
That rate has been steadily rising over the last 10 years.
Nationally in 2021-2022, only 64 per cent of mental health patients were seen within the clinically recommended time frame based on their triage score.
The Australasian College of Emergency Medicine (ACEM) found mental health patients typically became "stuck" in emergency departments.
They held a summit in 2018, and in 2020, published "Nowhere else to go", a report which called for more funding for inpatient mental health beds, better-connected community care services and better reporting on excessive lengths of stay in EDs.
ACEM president Clare Skinner said the mental health system was under enormous pressure.
"We're seeing shortages with beds, shortages with staff and also unfortunately gaps and shortages in the community services available for people who need them for mental health problems," she said.
"We choose to work in emergency departments because we really care deeply for people.
"The situation where we have people presenting in increasing numbers to seek our help, and we're not able to provide that care because the system is letting us down is deeply heartbreaking."
Myree hopes Ashley's story will help prompt reforms.
She and her sister have started a group in Ashley's memory focused on improving Australia's mental health system.
"Every mother says that their children are the light of their lives, and she was for us," Myree said.
"I'm really sad she's no longer here.
"She was my only child and so the gap in my life is huge."
