Coroner's Finding: MUNDY Michaela Jayne
Deceased
Michaela Jayne Mundy
Demographics
15y, female
Date of death
2012-07-09
Finding date
2014-03-12
Cause of death
neck compression due to hanging
AI-generated summary
Michaela Mundy, a 15-year-old with depression, was seen by CAMHS therapist Vina Hotich from July-November 2011, presenting with suicidal ideation, self-harm, and moderate-to-severe depressive symptoms. Despite evidence of clinical deterioration, risk escalation, and concerning features (possible psychosis, dissociation), Hotich assessed risk as low and did not consult psychiatry colleagues or refer to the multidisciplinary team. When Michaela disengaged in November 2011, CAMHS closed her file. Critical opportunities were missed: Seymour College and later Dr L. urged psychiatric involvement, but communication failures meant Michaela never saw a psychiatrist until too late. By June 2012, Dr G. prescribed fluoxetine but didn't escalate suicidal statements on final visit (5 July 2012). Michaela died by hanging 4 days later. The coroner found CAMHS operated as individual practitioners rather than as a multidisciplinary team, over-relied on rigid guidelines, failed to utilise available psychiatric expertise, and inappropriately withheld father's involvement despite his known concerns. Earlier psychiatric assessment and comprehensive risk management could have altered outcomes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- failure to refer to psychiatrist despite clinical deterioration and suicidal ideation
- inadequate risk assessment and reassessment
- underestimation of severity of depression
- rigid application of treatment guidelines without clinical judgment
- failure to utilise multidisciplinary team resources
- lack of mental state examination
- disengagement from CAMHS without appropriate follow-up or re-engagement
- missed opportunities to re-involve Michaela in treatment after self-harm
- poor communication between CAMHS, schools, and general practitioners
- failure to involve father in treatment planning
- inadequate supervision of junior clinician
- possible prodromal psychotic features not assessed
- dissociative symptoms not recognised as concerning
- medication initiated without adequate psychiatric oversight
Coroner's recommendations
- That the current approach of CAMHS in which it fails to take proper advantage of the multi-disciplinary team approach be reformed so that therapists such as Ms Hotich are no longer operating as individual practitioners
- That the number of psychiatrists employed within CAMHS be increased so that the current disincentive to refer a patient such as Michaela is removed
- That all services provided by CAMHS should be provided under the same level of consultant supervision as a surgical service in a public hospital, specifically under supervision by a consultant psychiatrist
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