Coroner's Finding: Youth Suicide

Contributing factors

• severe and unresolved childhood trauma including sexual abuse, physical abuse, neglect, and exposure to family violence
• inadequate child protection services response to notifications and cumulative harm
• severely under-resourced child and adolescent mental health services
• lack of dedicated adolescent inpatient mental health facility
• lack of outreach and flexible mental health service models
• homelessness and unstable accommodation
• media reporting of youth suicide breaching Mindframe guidelines and potential contagion effect
• poor inter-agency communication and lack of service coordination
• school disengagement and non-attendance
• substance abuse and self-harm
• lack of early intervention programs in infancy and early childhood
• parental mental illness and intergenerational dysfunction

Coroner's recommendations

1. Complete compliance with Mindframe Guidelines for all media reporting of suicide
2. Ongoing regular training for media staff in evidence-based suicide reporting guidelines
3. Development of relationships between media organisations and mental health services to manage impact of suicide reporting
4. Consultation with mental health and suicide prevention services prior to publication of suicide stories
5. Research into social media contagion effects and development of resources for online memorial pages and campaigns
6. Public education about potential effects of online reporting of suicide
7. Review of suppression powers under Coroners Act 1995 to allow coroner to suppress identity of deceased young person during investigation
8. Implementation of dedicated adolescent/youth portfolio within CPS with single point of accountability
9. Continued education of CPS workers on cumulative harm policy and practice
10. Regular audits of CPS files to assess compliance with cumulative harm assessment policy
11. Mechanism for CPS review of closed notifications and delayed closure until referral service effectiveness confirmed
12. Implementation of Out of Home Care Reform with trauma-informed evidence-based interventions for high needs children
13. Amendment of Housing Connect criteria to replace age minimum with independent income criterion
14. CPS review of all processes in assessing notifications involving youth homelessness
15. Government agency review of adequacy of accommodation and living options for homeless youth under 18
16. Enhancement of Tasmania Police IDM system to electronically forward relevant information reports to CPS
17. Consideration of embedding a Tasmania Police officer in CPS for information exchange
18. Compilation of comprehensive register of adolescent mental health services accessible to general practitioners
19. Compilation of register of general practitioners with interest/subspecialisation in adolescent mental health
20. Increased use of case conferencing by general practitioners with mental health specialists
21. Development of flexible and understanding appointment and billing arrangements in GP practices for youth mental health
22. CAMHS to provide consistent patient documentation and treating information to general practitioners
23. Department of Education review of policies on parental involvement in school counselling and disclosure of disclosures
24. Establishment of dedicated inpatient unit for adolescents aged 12-25 years with acute mental illness or suicidality
25. Alternative consideration of multi-disciplinary facility for young persons with acute mental health/suicidality with through-care and after-care model
26. Staffing of CAMHS to best practice standards with no referral freeze, elimination of waiting lists, clinical directorship, early intervention program for 0-3 years, and school-based multisystemic approach for 5-12 years
27. Establishment of statewide positions of suicide prevention coordinators for outreach between hospital discharge and service entry
28. Implementation of consistent statewide suicide risk assessment tool for emergency medicine presentations
29. Hospital policy for providing discharge summaries, contact details, and service information to patients and guardians after youth crisis admissions