Deceased
Katherine Aurelia Alexander
Demographics
34y, female
Coroner
Coroner Archer
Date of death
2017-02-07
Finding date
2024-07-25
Cause of death
multiple drug toxicity
AI-generated summary
Katherine Alexander, a 34-year-old woman with chronic suicidality and complex mental health conditions including bipolar II disorder, borderline personality disorder, and PTSD, died from multiple drug toxicity on 7-8 February 2017, two days after hospital discharge. She ingested prescription medications with clear intent to end her life. While the coroner found the final discharge decision was reasonable, significant clinical concerns were identified regarding continuity of care: a three-month gap without regular case management following her previous case manager's departure in November 2016, delayed transfer to a new community mental health team, and suboptimal discharge planning from the November 2016 admission. The transition of care between mental health teams was poorly managed despite clinicians' documented concerns about disruption to care. However, the coroner found these factors did not causally contribute to her death, which occurred in the context of chronic suicidality and multiple acute stressors including relationship breakdown, loss of support systems, and financial pressures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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