Coroner's Finding: HUGO-HORSMAN Jason William

Contributing factors

• failure to implement proper multidisciplinary team approach
• inadequate triaging and assignment of primary therapist without senior clinician input
• prolonged therapy with social worker without reassessment despite lack of improvement
• delayed referral to psychiatrist despite emerging suicidal ideation and self-harm
• poor communication between school counsellor and CAMHS
• inadequate documentation and lack of follow-up on school counsellor's report of suicidal ideation
• inadequate risk assessment despite identified self-harm behaviour
• poor handover from psychiatrist to social worker
• failure to inform parents of Jason's specific vulnerability when alone on Saturday evenings
• inadequate supervision and administrative oversight
• failure of general practitioner to contact CAMHS despite concerns
• disengagement from service at time of escalating risk without active re-engagement attempts

Coroner's recommendations

1. Implement genuine multidisciplinary team approach with triaging by most senior therapist in facility, not by telephone alone
2. Ensure all CAMHS therapists operate as part of multidisciplinary structure in concert, not as individual practitioners acting separately
3. Limit administrator input into therapist assignment decisions; administrator decision-makers should be psychologist or psychiatrist with full knowledge of client history
4. Mandate immediate referral to CAMHS psychiatrist if any suicidal ideation or self-harm identified, with continued psychiatrist oversight
5. Remind all therapists treating depressed young people that they must be aware of suicide risk and observe closely for increased risk regardless of therapy type or formal diagnosis
6. Require all risk assessments and management plans to be reviewed by psychiatrist for input and evaluation unless compiled by psychiatrist
7. Eliminate rigid 3-month or set-session requirement before considering referral to more senior therapist or medication; base decisions on clinical grounds
8. Review approach to antidepressant medication prescription in adolescents in light of recent evidence (specifically the Isacsson paper of 23 January 2014) and consider revised practices
9. Reinforce consultation with client's general practitioner regarding therapist type, therapy appropriateness, care plan, risk assessment, and medication appropriateness
10. Provide necessary resources to enable frequent meaningful consultation between therapists and psychiatrists, including employment of additional psychiatrists if required