Two days before 28-year-old Florence Le died, her family picked her up from the mental health facility she was staying in to celebrate the last day of Chinese New Year.
With big grins and full bellies after a dinner of snails and co*ckles, the five of them took a photo in front of the stone lions at the entrance to Chinatown in Western Sydney's Cabramatta.
They had no idea it would be their final moment together.
Forty-eight hours later, Florence — a Mum to two-year-old Noah, a concert pianist and a much-loved high school piano teacher — died by suicide inside Liverpool Hospital.
"We are just stuck with this guilt thinking was there something else we could have done?" Florence's younger sister Felicia said.
"We thought the hospital was the safest place for her to be, but it wasn't."
Six days before Florence died, she attempted suicide inside the hospital's acute adult mental health ward.
Her family say the hospital assured them Florence would be placed under the highest level of care, which included 24/7 supervision.
But on February 26, Florence's family say she was left alone for more than 20 minutes and she took her own life.
"We don't understand how this was allowed to happen," her older sister Fiona said.
"We thought we were sending her to a safe place, not a place to die — where else was she supposed to be?
"We shared everything together, we were the three peas in a pod, the three musketeers, the three sisters. We just feel completely numb."
Florence had been battling anxiety, which had gotten worse over the previous six months.
The Le family say the hospital did not contact them when Florence died, and they only found out because Fiona called to ask about her sister being discharged.
That's when the hospital told Fiona a serious incident had occurred, and she needed to come to the intensive care unit.
"When we asked what had happened, the hospital appeared to close ranks and we were entirely unclear about what had gone on," Fiona said.
"It was the most emotional and traumatic thing I've ever had to go through just watching my sister, laying in the hospital bed — lifeless.
"It's beyond belief and it's been so much harder to accept because it was a senseless, entirely avoidable loss."
A spokesperson for the South Western Sydney Local Health District said that as the case had been referred to the coroner, they were unable to make any further comment.
"South Western Sydney Local Health District extends its deepest sympathy to the family and loved ones of Florence Le for their loss," the spokesperson said.
Calls for more workers in mental health inpatient units
Florence's death follows the suicide of 24-year-old Aboriginal woman Makalie Owens inside St Vincent's mental health facility in Melbourne, just days prior.
Makalie's devastated family said they felt let down by the public health system which failed to keep their daughter safe, after Makalie went to hospital but was left unsupervised for what her family believe was too long.
The ABC has spoken to other people who had lost loved ones — mainly women aged in their 20s — to suicide inside mental health facilities who wanted to remain anonymous.
Data from the Australian Institute of Health and Welfare, obtained by the ABC, shows while recent rates are lower than 10 years ago, there was a slight increase in the number of inpatient suicides in the latest figures.
Eighteen people died by suicide in an acute psychiatric unit in 2020-21, up from 15 the year before.
A Royal Commission held into the Mental Health System in Victoria in 2021 recommended that suicides in healthcare settings should be one of the top priority areas for the government, to enable better oversight.
Dr Simon Stafrace from The Royal Australian and New Zealand College of Psychiatrists said there were many gaps in mental health services because the workforce hadn't been there.
But he said prevention of suicide on inpatient units was a major focus.
"Families entrust us with the care of their loved ones expecting that this will not happen … unfortunately sometimes these horrible outcomes do occur," he said.
"I know many psychiatrists that have found it really difficult to continue working in inpatient settings after events like this — it really changes the trajectory of people's lives."
Dr Stafrace said there are massive shortfalls in the number of psychiatrists in Australia and urged the federal government to step in and fund more training programs.
"It's ironic of course that we employ some of our most junior staff on our inpatient units and that's something we are keen to see change," he said.
"We want to see more expertise, more experience and more senior positions being funded in inpatient services."
Family calls for audits of mental health wards
Florence's mother Tammie and father Adam smile through sobs as they talk about their daughter, who fell in love with the piano in primary school.
They beam with pride as they reminisce about how she studied at the sought-after Sydney Conservatorium of Music, before becoming a music teacher at Kingsgrove High School and a performer at the Star Sydney.
But their smiles turn serious when they say there was "something wrong" with the care Florence was given in hospital.
"What do you expect when you put someone in hospital, you expect them to looked after," Adam said.
"We saw something so similar happen in Melbourne, what is wrong with the public system?
"We feel incredibly let down, how could you comprehend it? Florence has vanished forever."
Florence's parents say it's hard to imagine the impact her death will have on her son, who won't get to see how dedicated and loving his tenacious mother was.
"When you are young you are taught about fairytales, I know nothing can reverse this and nothing can bring back my Florence," Adam said.
"But by some miracle I just wish for her back, I wish for a time machine."
The Le family are now calling for audits of mental health wards to ensure they are adhering to standards and improved training and better pay and conditions for nurses to address burnout and compassion fatigue.
"Florence didn't want to die, she just couldn't see how she could go on, because she was suffering excruciating emotional pain," Fiona said.
"It's the most horrible and heartbreaking thing to go through and I don't want anyone else's family to go through something like we have.
"We have a piece of us that is going to be missing for the rest of our lives."
Posted, updated
