Coroner's Finding: JORKOWSKI Natassja Alexandra

Contributing factors

• chronic bilateral uveitis with resultant cataracts and permanent vision damage
• reactive depression secondary to visual impairment
• pre-existing chronic dysthymia and suicidal ideation since age 13
• failure of ACIS to provide urgent psychiatric assessment despite explicit written suicide plan
• inappropriate risk classification (Level 2 non-urgent) by Mental Health Triage Service
• missed psychiatric appointment due to scheduling error (Thursday 28 May vs Friday 29 May)
• patient declining rescheduled appointment on 2 June without follow-up escalation
• structural inadequacy of ACIS to manage rare high-risk cases
• absence of mandatory psychiatric review despite detailed written suicide plan

Coroner's recommendations

1. The Chief Psychiatrist of South Australia should consider this finding and the views of Professor Goldney
2. The Assessment and Crisis Intervention Service should develop a risk management framework to identify outlying cases such as Natassja's with a view to fast-tracking psychiatric assessment