“More needs to be done to prevent unexpected, unnatural or violent deaths in the mental health system - and to ensure grieving families and the public are told why such deaths are occurring, and at such a high rate.” said Colleen Pearce, The Public Advocate. The number of deaths in mental institutions called the state’s urgent attention. For two years, 36 deaths were recorded due to unnatural and unexpected causes.

The call was strengthened by the results of the investigation. It was said that in 2010, the government was warned that most psychiatric deaths are due to illegal or unethical practices. The rise of unexpected deaths also strengthens the assumption of malpractice. Sherene Devanesen, the chief of Peninsula Health, also claimed that there were three unnatural deaths in a psychiatric ward for a short period of time.

A need for immediate action was pushed through when stories of maltreated patients were known. The story of Anthony Travaglini caught everyone’s attention. Travaglini was a psychiatric patient died on the arms of a very aggressive staff. Witnesses said that the staff medicated the patient repeatedly despite the patient’s deteriorating state. The statements of the witnesses were supported by the result of the pathologic examination to the patient. According to forensic tests, the death of Travaglini was caused by mixed combination of different drugs.

The Saturday Age revealed that Travaglini’s case is among the three cases of unexpected, unnatural, and violent psychiatric deaths caused by the failings of senior mental health staffs. The Age also suggested an overhaul of the psychiatric system in Victoria to assure quality of health services and most importantly to avoid unexpected deaths. This is supported by the Office of the Public Advocate. The group also claims that it is also necessary to provide more information to the public about the real cause of death.

Pearce responded to The Age’s call of 36 unexpected deaths in 2 consecutive years. The Coroners Prevention Unit provided this figure inside mental health units from 2008 to 2010. It was also revealed that one-fourth of Victoria’s coronial inquests involved people with mental illnesses.

''The question for us is why? Why did they die, how could they die [in a mental health facility] and what can we do to prevent it? Families want answers … Why shouldn't families know why their loved ones have died and what did the system do to improve or address the problem?'' said Pearce. She asked the team of The Age to help her with her claims.

''I would like an audience with you to bring to your attention in confidence some of the practices that are causing such poor outcomes and suffering. I have tried to raise these issues locally but unfortunately been met with vicious attacks on my personal and professional reputation.'' Pearce added. The Age received emails from psychiatrists and even from currently employed health workers supporting Pearce’s claims. This should be the start of the state’s immediate action against violent, unnatural, and unexpected deaths caused by mistreatment.