Coronial
SAhospital

Coroner's Finding: HOWARD Miranda Robyn and MCPHERSON-SMITH Aurora Holly Violet

Deceased

Miranda Robyn Howard and Aurora Holly Violet McPherson-Smith

Demographics

female

Date of death

2013-11-27 and 2015-07-01

Finding date

2018-03-05

Cause of death

Miranda Howard: aspiration pneumonia complicating overdose of prescription medications (Quetiapine) on background of borderline personality disorder. Aurora McPherson-Smith: multi-organ failure due to ingestion of concentrated hydrochloric acid.

AI-generated summary

Two young women with borderline personality disorder (BPD) died by suicide after inadequate mental health care in South Australia. Miranda Howard (22) died from aspiration pneumonia following overdose; Aurora McPherson-Smith (18) from multi-organ failure following hydrochloric acid ingestion. Both were initially misdiagnosed (psychosis/depression), experienced delayed BPD diagnosis, and received fragmented, inconsistent care across public and private services. Critical failures included: lack of early BPD diagnosis, inadequate specialist clinicians, reliance on medication and hospitalisation rather than evidence-based psychotherapy (DBT/MBT), poor therapeutic boundaries (particularly with Ms McPherson-Smith's therapist), abrupt service termination without transition plans, and lack of coordinated care. Clinicians were working without adequate training, mentoring or support in a system the coroner described as 'chaotic' and 'fragmented'. The state government failed to implement recommendations from a 2013 expert work group or national guidelines on BPD treatment, leaving both young women and families without access to specialist services available in other states.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

psychiatrypsychologyemergency medicine

Error types

diagnosticcommunicationsystemdelay

Drugs involved

quetiapinesertralineolanzapinearipiprazolerisperidoneamisulpridelithiumasenapinefluvoxaminefluoxetinevenlafaxineparacetamolmorphinemidazolamhydrochloric acid

Clinical conditions

borderline personality disorderchronic suicidal ideationself-harm/self-harming behaviourdepressionanxietyobsessive-compulsive disordereating disorderdissociationaspiration pneumoniapolypharmacy toxicitymulti-organ failure

Contributing factors

  • misdiagnosis of psychosis/schizoaffective disorder instead of borderline personality disorder
  • significant delay in diagnosis of BPD (15 months for Miranda, 20 months for Aurora)
  • lack of specialist BPD clinicians with appropriate training and experience
  • absence of evidence-based treatments (DBT, MBT) in both public and private sectors
  • fragmentation between public and private mental health services with poor coordination
  • reliance on medication and hospitalisation as primary treatment rather than psychotherapy
  • inadequate therapeutic boundaries in therapist-patient relationships
  • abrupt termination of psychiatric care without transition planning (Dr B.)
  • insufficient supervision and mentoring of junior clinicians
  • lack of crisis management plans despite severe suicide risk
  • dangerous polypharmacy with medication prescribed by multiple practitioners
  • frequent emergency department presentations and admissions that interrupted therapy
  • accommodation services not equipped to provide therapeutic support
  • failure by government to implement expert recommendations on BPD service delivery
  • inadequate communication and coordination between different healthcare providers

Coroner's recommendations

  1. Fullarton Private Hospital to adopt policy prohibiting transport of at-risk patients by taxi/chauffeured service unless accompanied by qualified nurse/hospital employee
  2. State Government to immediately identify and allocate funding for full assessment of Spectrum Personality Disorder Service (Victoria) as prototype model for South Australia
  3. State Government to immediately identify and allocate funding for full assessment of Orygen Youth Service HYPE program as prototype model for adolescent BPD treatment in South Australia
  4. State Government to adopt and implement as matter of urgency the recommendations in the South Australian BPD Work Group final report (June 2014)
  5. Immediate creation of BPD Coordinator position to be advertised nationally and internationally for suitably qualified person with appropriate clinical expertise
  6. Engagement of Dr K. OAM as consultant to State Government to: provide advice on development and implementation of BPD Work Group recommendations; oversee revision and simplification of SA Mental Health Commission Action Plan 2017-2020; provide supervision and advice to Project Steering Committee; ensure new Action Plan incorporates National Guidelines (2013); chair panel for BPD Coordinator selection
  7. State Government to enter into negotiations with public sector stakeholders regarding policies that exclude private psychiatrists from clinical role in management of BPD patients under their care who are admitted to public hospitals
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