Inquest into the death of JY
Deceased
JY
Demographics
5y, male
Date of death
2018-06-08
Finding date
2023-07-05
Cause of death
multiple stab wounds
AI-generated summary
A 5-year-old boy died from multiple stab wounds inflicted by his father during an acute psychotic episode. The father, diagnosed with schizophrenia in 2003, was admitted to Hornsby Hospital in April 2018 following deterioration. His medication was changed from risperidone depot to aripiprazole depot during admission, with quetiapine increased to 300mg. Upon discharge on 16 May, discharge planning and medication communication to family were inadequate. The father was referred to a different Local Health District's community mental health team (Hills MHT), but information transfer between services was incomplete, with the complete discharge summary not reaching Hills MHT until 30 May. Despite clear signs of deterioration including delusions that his son was 'the devil', attendance at Palmerston Centre on 6 June seeking admission, and explicit family concerns about risk to the child, the father was not admitted to hospital. Red flags regarding risk to the child were known to clinicians but not adequately weighted in decision-making. Critical systemic failures included incomplete inter-LHD communication, unclear discharge documentation about medication cessation, and insufficient escalation despite family-raised concerns.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- inadequate medication management during transition between facilities
- incomplete discharge summary communication between Local Health Districts
- medication dosing confusion regarding oral aripiprazole cessation
- family concerns about risk to child not adequately weighted in clinical decision-making
- failure to admit patient to hospital on 6 June 2018 despite clear deterioration and family-expressed concerns
- insufficient escalation and communication between Hornsby Hospital and Hills Community Mental Health Team
- unclear documentation regarding medication changes at discharge
- inconsistent assessment of risk and minimisation of family concerns
- possible non-adherence or confusion regarding prescribed medication dosages
Coroner's recommendations
- That consideration be given to expanding the REACH (Recognise, Engage, Act, Call, Help) program to Community Mental Health settings, with appropriate information being provided to consumers, families, and other carers on how to use the program in that setting
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