Inquest into the death of Madeline Downman
Deceased
Madeline Jocelyn Rose Downman
Demographics
17y, female
Date of death
2014-06-06
Finding date
2016-06-08
Cause of death
self-inflicted hanging
AI-generated summary
Madeline (Maddy) Downman, 17-year-old Aboriginal girl in state care, died by hanging at a residential facility. She had complex psychiatric needs including depression, trauma, self-harm, and substance abuse, with four years of unstable placements (26 total) and fragmented mental health care. Despite evidence of mood disorder and suicide risk, she disengaged from psychological counselling in January 2014 and refused further treatment. Key failures included: inadequate care planning, poor information sharing between DCF and her psychologist, lack of formal diagnosis despite clear clinical need, absence of substance abuse referral, and no integrated approach to her care. However, her capacity to refuse treatment and extreme proximity to age 18 (when state care ended) limited what legally could be imposed. The coroner found systemic failures but concluded prediction of suicide is impossible and failures did not necessarily contribute to her death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- complex trauma from domestic violence and sexual abuse
- undiagnosed borderline personality disorder or emerging borderline personality disorder
- severe depression and anxiety
- substance abuse (alcohol, marijuana, petrol sniffing) without specialist intervention
- multiple placement instability (26 placements in 4 years)
- disengagement from psychological treatment
- failure to share information between mental health providers and DCF
- lack of formal psychiatric diagnosis despite clear clinical need
- inadequate care planning and poor transition planning
- insufficient collaboration between agencies
- young person's refusal to engage with treatment
- approaching age 18 with anxiety about loss of care
Coroner's recommendations
- The Minister for Children and Families direct all case managers provide formal written confirmation of any and all information exchanged between case managers at the time of handover of any case relating to a child in care under the Care and Protection of Children Act
- The Minister of Health favourably consider the eight recommendations made by Dr P. regarding improvements to mental health systems, particularly in relation to communication between agencies, formal diagnostic processes, and services for young people transitioning to adulthood
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