Deceased
Caitlin Wilkinson Whiticker, Talieha Nebauer, William Johnathan Fowell
Demographics
18y, female, female, male
Date of death
2014-08-05, 2014-04-06, 2014-06-10
Finding date
2019-08-30
Cause of death
Caitlin: suicide by hanging; Talieha: suicide by hanging; William: suicide by train
AI-generated summary
Three adolescent patients (aged 18 at death) died by suicide within four months of the Barrett Adolescent Centre (BAC) closure in January 2014. Caitlin had complex mental health needs including bipolar affective disorder and PTSD; she lived with her mother and a family member with whom she had a dysfunctional relationship, medication non-compliance (particularly lithium), housing instability, and recent relationship breakdown. Talieha had post-traumatic stress disorder and borderline personality disorder from childhood sexual abuse; she transitioned to an adult facility (PRCCU) with reduced supervision than anticipated, and experienced a distressing incident before her death. William had intellectual disability, anxiety, and profound abandonment issues; he transitioned to temporary disability-supported accommodation with inadequate mental health service linkage and later his father departed for Canada. While transition arrangements were documented as adequate by inquiries, systemic gaps in adolescent-to-adult mental health service alignment, inadequate mental health support for those with dual diagnosis, loss of continuity of care for complex cases, and housing instability emerged as contributory factors. No findings suggest clinical errors directly preventable; rather, the timing of closure and systemic service gaps created vulnerability.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
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