Inquest into the death of A P
Demographics
2y, female
Date of death
2016-09-10
Finding date
2020-06-01
Cause of death
drowning
AI-generated summary
A 2-year-old child died by drowning at her home in September 2016. Her mother was suffering from acute psychosis and had stopped taking antipsychotic medication days before the death. Critical failures occurred: the child protection service had closed the case file prematurely in February 2015 despite known severe maternal mental illness and prior child removal; the community mental health team discharged the mother on 9 September despite her documented deterioration; and most significantly, an urgent referral from the treating GP on 9 September alerting the mental health emergency team to the mother's acute relapse was never actioned—no record was found and no clinical response was initiated. Had the referral been processed appropriately, immediate mental health intervention could have prevented the death. Systemic failures included poor inter-agency communication, inadequate supervision of junior staff, absence of psychiatrists from multidisciplinary team meetings, and lack of coordination between child protection and mental health services.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- mother's acute psychotic relapse with religious delusions
- non-compliance with antipsychotic medication (triflouperazine)
- premature closure of child protection case file by DCJ in February 2015
- inappropriate discharge decision by Liverpool Community Mental Health Team on 9 September 2016
- failure to action urgent GP referral on 9 September 2016—referral was received but not processed
- failure to build rapport and foster engagement with mother
- inadequate supervision of newly appointed Clinical Care Coordinator
- absence of treating psychiatrist from multidisciplinary team meetings
- poor inter-agency communication between child protection, mental health, and general practice
- lack of follow-up and documentation of missed appointments
- flawed risk assessments by child protection using structured decision-making tools
- possible medication dosage reduction without consulting prescribing psychiatrist
Coroner's recommendations
- Department of Communities and Justice: Implement policy requiring consultation with key mental health services before closing high/very high risk child protection cases involving parent/carer with known current severe mental health disorder; support policy with case-based training
- Department of Communities and Justice: Review existing policy and practice mandates to strengthen guidance around case closure, particularly for high/very high risk cases involving parent/carer with severe acute or persistent mental health disorder
- Ministry of Health: Conduct review of adequacy of existing policies to strengthen guidance on clear and regular communication and clear lines of responsibility between LHDs and GPs where mental health care is shared; develop simple policy formulation supported by ongoing training
- Ministry of Health: Review mandatory training for Case Care Coordinators offered through HETI or other forums, considering incorporation of de-identified case study highlighting need for enhanced communication between shared care providers and for prioritising rapport building
- Ministry of Health: Ensure LHDs remind GPs of their right to receive direct contact telephone numbers of the Case Care Coordinator and Team Leader responsible for consumer care in shared mental health services
- South Western Sydney Local Health District: Conduct training for all CCCs on case coordination role, strategies for engaging with stakeholders, and rapport building and consumer relationship maintenance techniques
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