Investigation into the Gold Coast Child and Youth Mental Health Service
Background into the review
Under the Mental Health Act an independent review was established to review the model of care used in the Gold Coast Child and Youth Mental Health Service, and identify themes, lessons and actions that can inform system improvements and strengthen mechanisms to mitigate preventable harm.
On 5 November 2025 the Chief Psychiatrist appointed four independent, external Inspectors to undertake the investigation. The investigation was led by Dr Paul Denborough, Director, Infant Child, Youth and headspace Alfred Health Victoria.
The report on the Investigation into the Child and Youth Mental Health Service, Gold Coast Authorised Mental Health Service (PDF 551 kB) was published in April 2026.
The review made 11 recommendations across the following areas,
- Workforce development including family engagement
- Eating disorder services models of care
- Partnerships and integration
- Lived experience workforce
- Clinical practice and safety
- Clinical governance
- Patient rights
- Incident management and post-incident support
- Crisis responses
- Consumer, family and carer engagement
The review and recommendations have been strongly informed by the voices of consumers, families and carers, recognising the essential role lived experience voices have in supporting service system improvement and reform. The Inspectors acknowledge the courage of those who engaged in the process, including staff who engaged in the process with a commitment to learning and practice improvement.
Acknowledgment and thanks are also extended to the Mental Health Lived Experience Peak Queensland and ARAFMI for supporting consumer, family and carer engagement in the review.
Supports available
Queensland Health recognises the impact of adverse events on consumers, families and carers, staff, and the wider community. If you or a loved one is experiencing distress or discomfort, it is encouraged that you speak to your general practitioner and/or other support person about any concerns you may have. Support can also be accessed via 1300 MH CALL (1300 64 22 55). MH CALL is a 24-hour, seven-day centralised phone number for mental health referrals, crisis and support.
Additional support is available to families through ARAFMI 24/7 on 1300 554 660. ARAFMI offers a range of free support services for mental health carers in Queensland. These are specifically designed for anyone providing unpaid care for a family member, friend or community member experiencing mental ill-health. To schedule a 1:1 session please call between 9am and 4pm Monday to Friday.
For Queensland Health staff, to access your EAP provider, please see the EAP provider page on QHEPS.
You can also call the following crisis and support helplines, 24 hours a day, 7 days a week.
- Lifeline: 13 11 14
- Kids Helpline: 1800 551 800
- 13YARN: 13 92 76 to talk with an Aboriginal or Torres Strait Islander Crisis Supporter
If you or someone you know needs immediate help call Triple Zero (000) or go to your nearest emergency department.
Our response
Queensland’s authorised mental health services address highly complex mental and behavioural disorders among adolescents and young adults. These disorders are associated with increasing distress for the young people themselves and for their families and carers. Treatment and care needs to be a collaborative process which addresses the needs of the young person and involves their support networks. Mental health services have long recognised this and have processes for ensuring collaborative care. However, at times, effective engagement of both young people and their support networks can pose challenges for services and for service providers.
In line with Chief Psychiatrist investigations under the Mental Health Act, the Gold Coast Authorised Mental Health Service is required to prepare and submit an implementation plan to the Chief Psychiatrist.
The Gold Coast Authorised Mental Health Service has accepted the recommendations and is progressing the development of the implementation plan with required timeframes. The service is continuing to progress work aligned with recommendations to ensure the provision of ongoing safe and effective care.
The Office of the Chief Psychiatrist will oversee and monitor the implementation of recommendations, including statewide recommendations and learning opportunities.