Deceased
FR
Demographics
27y, female
Date of death
2020-07-28
Finding date
2023-07-24
Cause of death
carbon monoxide intoxication due to voluntary and intentional inhalation of exhaust from a petrol generator
AI-generated summary
A 27-year-old woman with a lengthy history of depression, anxiety, and previous suicide attempts died by carbon monoxide poisoning. She was referred to mental health crisis services on 4 July 2020 with documented suicidal ideation. Despite the referral and her proactive contact requesting psychological support, she was never seen by any mental health clinician. Her case was discussed at five multidisciplinary team meetings over 18 days, transferred between teams, and she was discharged without ever receiving direct care. The coroner found she was 'very poorly served' by mental health services at a time she plainly needed support, highlighting critical failures in establishing therapeutic relationships and providing timely intervention.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
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36y · Male·Drowning
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Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
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