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
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Source and disclaimer
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