Finding into death of Melanie Anne Reynolds

Contributing factors

• Borderline personality disorder with acute exacerbation
• depression
• suicidal ideation
• inadequate transition planning from public to private mental health care
• lack of planned follow-up contact after CATT assessment
• CATT staff lack specific BPD training
• patient did not disclose suicide plan despite procuring lethal means
• access to prescription medications with lethal potential
• chronic suicidality with acute crisis period
• stress from unreliable casual employment

Coroner's recommendations

1. Spectrum should assess whether available BPD-specific training meets the needs of CATT/ECATT clinicians whose focus is on short-term assertive follow-up and transfer of care back to private practitioners, rather than ongoing treatment
2. If current training is found inadequate, Spectrum should work with CATT/ECATT teams to develop BPD-specific training suitable to the needs of CATT/ECATT clinicians
3. All public mental health services should encourage CATT/ECATT team members to participate in BPD-specific training
4. Improved transfer of care protocols should involve multi-disciplinary review, clear communication between public and private practitioners, clearly articulated plans stipulating timing of transfer, future roles, and patient involvement in disengagement planning