An expert has slammed the "reprehensible" actions of ACT Health and the doctors who discharged a psychotic patient three times before the man set fire to a hotel, saying they were "negligent in the extreme".
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In a scathing report, psychiatrist Dr Richard Furst also called for an independent investigation into Canberra Hospital's processes around discharging "chronically psychotic and dangerous patients".
He wrote that it was only a matter of good luck that no one had been killed or seriously injured because of the "grossly deficient" care that had indirectly caused the fire.
Dr Furst's report on the matter was tendered to the ACT Supreme Court on Monday, when the 34-year-old patient was found not guilty of arson and six property damage charges by reason of mental impairment.
A statement of agreed facts shows the man started a fire inside the Woden Hotel early on May 12 last year, damaging the interior and walls.
He then lit six small blazes in bins around the nearby Westfield shopping centre.
The man, who has a long history of mental illness, had been admitted several times to a mental health unit at Canberra Hospital in the months leading up to the fires.
He was repeatedly discharged, however, despite being homeless and in a psychotic state.
Dr Furst, a Sydney-based psychiatrist who was asked to assess the man as part of the court proceedings, outlined in his report how the man had been diagnosed with schizophrenia in 2006.
The man told Dr Furst that he had lit the fires on the morning in question because he was scared and voices had told him to do so.
"I thought demons were there to get me and could only be stopped by fire," the man said. "The voices said that."
Dr Furst said he believed that at the time of the incidents, the man could not control his conduct and did not know it was wrong.
"In my opinion, the actions of the psychiatrists 'treating' [the man] between February and April 2020, and ACT Health generally, by discharging him on three occasions in a psychotic state without stable accommodation and without any feasible discharge plan were reprehensible and negligent in the extreme," he wrote.
"Furthermore, it is only through good luck, rather than good management, that neither [the man] nor any member of the community were seriously injured or killed as a consequence of those grossly deficient episodes of 'care' and poorly thought out discharge plans."
In court on Monday, Justice Chrissa Loukas-Karlsson was struck by the gravity of Dr Furst's comments.
"They are, of course, very strong words, and it appears aptly strong," she said.
The judge characterised what had occurred in the man's case as "very concerning", and said it was important that the relevant authorities ensured safety for patients and the wider community.
Crown prosecutor Marcus Dyason, in consenting to special verdicts of not guilty by reason of mental impairment, described the health authorities as having committed "significant failings".
Defence barrister Jon White SC agreed, and told the court his client was now making "excellent progress in the community" under the care of Canberra Recovery Services.
Justice Loukas-Karlsson acknowledged this, but said she still believed it was appropriate to order that the man submit to the jurisdiction of the ACT Civil and Administrative Tribunal, which may make orders about his treatment under the Mental Health Act.
The Canberra Liberals' health spokeswoman, Giulia Jones, said this case was "yet another example of Canberra's health system struggling to cope as a result of underinvestment for over 10 years".
"We are playing catch-up," she told The Canberra Times.
"Mental health patients deserve better care, not being discharged into homelessness. Staff deserve better support."
Minister for Mental Health Emma Davidson said the ACT government was now funding and working with the Mental Health Foundation to deliver a pilot program that would ensure people discharged from acute care were not left homeless.
"The pilot is currently being delivered and provides transitional supported accommodation to people who are discharged from the adult mental health unit," Ms Davidson said.
"Designed to support transition from acute mental health care back into the community, [the Discharge Accommodation Program] works with participants to identify their goals and connect them with appropriate supports."
