Coroner's Finding: Ms G de-identified
Demographics
female
Date of death
2014-11
Finding date
2015-10-02
Cause of death
hanging (suicide)
AI-generated summary
Ms G, a woman in her forties with bipolar II disorder, generalised anxiety disorder, and severe alcohol dependence, died by suicide in November 2014. She had been admitted to hospital six times for detoxification and mental health treatment between 2009 and 2013, but remained non-compliant with follow-up care and repeatedly relapsed into alcohol and drug use after discharge. Financial difficulties, unemployment, and loss of private health insurance limited her access to ongoing specialist psychiatric support. Despite her psychiatrist's efforts and prescriptions for home detoxification, she was unable to sustain abstinence. The coroner identified inadequate outpatient support and supervision following hospital discharge as a systemic issue, and recommended development of multidisciplinary addiction support teams with nurse practitioner pharmacotherapy input to help break the cycle of addiction.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- severe alcohol dependence with repeated relapses
- bipolar II disorder
- generalised anxiety disorder with panic attacks
- inadequate outpatient support and supervision following hospital discharge
- financial difficulties and housing insecurity
- unemployment
- loss of private health insurance preventing further private hospital admission
- refusal to access public health system or Alcohol and Drugs Service
- non-compliance with psychiatric follow-up
- death of father from terminal cancer
- disruption to family and employment
Coroner's recommendations
- Development of appropriate ongoing outpatient support and supervision programs for patients following discharge from hospital for addiction treatment
- If addiction medicine specialists are not available, consider multidisciplinary support teams with pharmacotherapy input from suitably qualified nurse practitioners to help patients break the cycle of addiction
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