Inquest into the death of Fiona Goodberg

Contributing factors

• severe postpartum obsessive-compulsive disorder
• fragmentation of care with no single care coordinator
• inadequate antenatal mental health screening
• incomplete referral letter to inpatient unit omitting severity and diagnostic considerations
• premature discharge from St John of God Hospital after 2 days
• failure to fully consider nursing observations documenting impaired insight and possible delusional thinking
• missed opportunity to refer to community mental health team when triage nurse misinterpreted patient's consent
• inadequate mental health training of police and ambulance responders
• benzodiazepine medication reducing anxiety and fear of death
• no single clinician responsible for care coordination in final days before death

Coroner's recommendations

1. NSW Health consider whether current capacity of Mother/Parent-Baby Units is sufficient for both metropolitan and regional areas
2. NSW Health and Nepean Blue Mountains LHD investigate advantages and disadvantages of direct referral from inpatient mental health units to community mental health teams without triage through Mental Health Line
3. NSW Health and Nepean Blue Mountains LHD consider whether appropriate safeguards exist and sufficient guidance provided to overcome fragmentation of care when mental health consumer receiving treatment from different providers across public and private sectors without single care coordinator
4. St John of God Burwood Hospital consider whether policies regarding obtaining collateral information from referring clinicians should impose stricter timeframe and what clinical indications warrant such timeframes
5. NSW Commissioner of Police consider whether NSW Police Officers have adequate training to: apply provisions of NSWPF Handbook regarding alternative options for mental health intervention including how to employ them and in what circumstances; and respond appropriately to concern for welfare reports regarding mental health status