Olivia Gilfillan, aged 23, died between 1–5 February 2018 after nine years of psychiatric treatment for anorexia nervosa, obsessive-compulsive disorder, schizoaffective disorder, and borderline personality disorder. She was discharged from Shellharbour Mental Health Rehabilitation Unit in November 2017 into community care. The discharge plan included case management, supportive workers, and intended psychiatrist follow-up, but she was never connected with a community psychiatrist despite this being identified as important. Between discharge and her death, she had four brief hospital admissions for self-harm and suicidal ideation. On 1 February 2018, after her case worker arranged hospital assessment against her wishes, Olivia went missing. Her remains were found on 5 February. The coroner found the discharge plan itself adequate and the treatment decisions reasonable, but highlighted the critical gap: Olivia's lack of engagement with a community psychiatrist despite clear clinical indication. The cause and manner of death remain unascertained.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
failure to connect Olivia with community psychiatrist despite being identified as important element of discharge plan
extensive prior institutionalisation and trauma from prolonged hospitalisation causing institutionalisation and lack of individuation
anorexia nervosa with rare features including psychotic symptoms and catatonia
chronic suicidal ideation and self-harm behaviour
complex comorbid mental health conditions
discontinuation of ECT and antipsychotics based on change in diagnosis from schizoaffective disorder to borderline personality disorder
cognitive impairment attributed to anorexia and extensive ECT
Coroner's recommendations
No formal recommendations made; coroner noted that current ISLHD practice has improved to ensure psychiatrists are embedded in continuing care teams and available to discharged patients
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