Coronial
VICcommunity

Finding into death of Mikael Chandra Rohan

Deceased

Mikael Chandra Rohan

Demographics

14y, male

Coroner

State Coroner Judge Ian L Gray

Date of death

2010-11-16

Finding date

2010

Cause of death

head injuries when struck by a train

AI-generated summary

Mikael Rohan, a 14-year-old with a history of separation anxiety, attachment disorder, and sleep disturbance, died after stepping in front of a train on 16 November 2010. He had recently been distressed about a reported pregnancy with a girlfriend and experienced a rapid deterioration following his girlfriend ending their relationship. His presentation to Monash on 9 November 2010 with suicidal ideation was assessed by a psychiatric nurse (Nurse Sebille) rather than a child and adolescent psychiatrist as requested by his GP. The assessment was rated as low risk and discharged. Care became fragmented when Dr O.'s treatment was terminated in favour of Headspace counselling. Clinicians did not utilise adequate senior psychiatric review of an adolescent in crisis. The coroner noted that terminating the established therapeutic relationship with Dr O. may have removed a stabilising influence during a high-risk period, though acknowledged the complexity of predicting suicide risk in adolescents.

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Specialties

psychiatrygeneral practiceemergency medicine

Error types

diagnosticcommunicationsystem

Drugs involved

temazepamlovan

Clinical conditions

separation anxietyattachment disordersleep disturbancedepressionanxietysuicidal ideationcompleted suicide

Contributing factors

  • inadequate senior psychiatric review of crisis assessment performed by adult mental health nurse
  • fragmentation of care with termination of established psychiatric relationship
  • insufficient family engagement in care coordination decisions
  • rapid escalation of risk in 5-day period preceding death
  • limited time window between first clear risk presentation and completed suicide
  • adolescent's difficulty with risk assessment reliability
  • relationship breakdown shortly before death

Coroner's recommendations

  1. Monash Medical Centre should review its Crisis Assessment Review policies to require an experienced Child and Adolescent Psychiatrist to review adolescent crisis assessments, particularly those undertaken by adult mental health clinicians, before clinical decisions regarding admission, treatment or discharge are made
Full text

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