Inquest into the death of Camilla MARGOLIS
Deceased
Camilla Margolis
Demographics
34y, female
Date of death
2018-05-10
Finding date
2022-02-01
Cause of death
multiple blunt force injuries
AI-generated summary
Camilla Margolis, 34, died by suicide at Echo Point Lookout in the Blue Mountains hours after discharge from mental health inpatient care. She had complex borderline personality disorder with chronic suicidality across 20+ hospital admissions over several years. Critical clinical lessons emerged: (1) Fragmentation of electronic records prevented clinicians from accessing knowledge that she had explicitly stated plans to jump from the Blue Mountains during her discharge assessment—had this information been available, detention may have been reconsidered; (2) Communication failures occurred when significant new information from her support person about imminent risk was not escalated to her treating psychiatrist who was off-ward; (3) Discharge planning lacked adequate consideration of transport logistics and protective measures given her known location-specific fixation; (4) Absence of verbal handover to community services meant continuity of care was not properly established. System improvements addressing fragmented records, communication protocols for off-duty consultants, and structured discharge planning have since been implemented.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- fragmented electronic patient records preventing access to critical information about stated suicide plans
- communication failure—information from support person about imminent suicide risk not escalated to treating psychiatrist
- inadequate discharge planning regarding transport needs and protective logistics
- absence of verbal handover to receiving community mental health team
- treating psychiatrist unavailable on ward at time of discharge decision
- delayed identification of premeditated plan to travel to specific location for suicide
- lack of structured assessment procedure for patients discharged geographically distant from residence
- chronic complex personality disorder with treatment resistance and ambivalence regarding mental health engagement
Coroner's recommendations
- Implementation of systems to consolidate fragmented electronic medical records across Local Health Districts to enable clinicians to access comprehensive patient history—NSW Health initiatives including HealtheNet Clinical Portal, Single Digital Patient Record program, and Clinical Health Information Exchange have been progressed to address this (no additional recommendation made as NSW Health already acting)
- Development of formal guidance and documentation procedures regarding expectations for contact of treating consultants when absent from ward—NBMLHD issued the Mental Health: Communication and care arrangements by admitting inpatient consultants for management decisions outside of rostered hours procedure (December 2021) requiring SMOs to document contact preferences
- Enhanced discharge planning procedures to ensure verbal handover to receiving community mental health teams—NBMLHD Mental Health: Transfer of Care Procedure (September 2018) now requires prompt phone contact with receiving CMH team and verbal handover using ISBAR tool
- Systematic consideration of patient transport needs in discharge planning, particularly for patients discharged geographically distant from residence—NBMLHD issued November 2021 Memorandum regarding discharge planning and patient transport logistics inviting teams to consider strategies for mitigating risk including transport options and triggers for specific locations
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