Coronial
VIChome

Finding into death of Tamara Ann Burt

Deceased

Tamara Ann Burt

Demographics

32y, female

Coroner

Coroner Jacqui Hawkins

Date of death

2011-03-07

Finding date

2014-11-11

Cause of death

Alcoholic ketoacidosis

AI-generated summary

Tamara Burt, 32, died of alcoholic ketoacidosis after isolating in her room and drinking excessively. She had bipolar affective disorder, alcohol dependence disorder, and borderline personality disorder traits. Despite outpatient mental health treatment through MSTS and alcohol counselling through EDAS, her care was fragmented across three separate services without coordinated case management. She had been successfully stabilised in a structured community care unit but struggled after discharge to independent supported accommodation. Key clinical lessons: (1) complex dual-diagnosis patients require more integrated, coordinated care rather than compartmentalised services; (2) the management plan emphasising client autonomy and self-responsibility was inappropriate for someone unable to self-care during crises; (3) medication non-compliance and escalating risk indicators (incontinence, isolation, alcohol use) required earlier proactive intervention; (4) supportive housing discharge planning failed to account for her need for ongoing structure; (5) co-residents felt burdened by implicit care responsibility despite being told otherwise.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatryaddiction medicinegeneral practice

Error types

systemcommunicationdelay

Drugs involved

quetiapinesodium-volproatelamotriginealcohol

Clinical conditions

alcoholic ketoacidosisbipolar affective disorderalcohol dependence disorderborderline personality disorderchronic binge drinkingmedication non-compliancemental health crisisdual diagnosis

Contributing factors

  • chronic alcohol abuse and binge drinking
  • non-compliance with psychiatric medications
  • bipolar affective disorder
  • alcohol dependence disorder
  • suspected borderline personality disorder
  • accommodation instability and housing stress
  • mental health decline
  • social isolation in bedroom
  • lack of coordinated care between services
  • compartmentalised service delivery
  • inadequate crisis response planning
  • unsafe discharge from structured care to independent living
  • co-residents' inability to recognise or respond to crisis

Coroner's recommendations

  1. Services should be flexible and responsive with support and management when clients are unable to self-care, identifying appropriate points for higher levels of support in management plans
  2. Multiple services caring for one person with interlinked mental health, alcohol abuse and accommodation issues should avoid compartmentalisation and work in partnership
  3. Consider forming partnership agreements with regular case management meetings between different services to ensure awareness of roles and responsibilities and holistic management
  4. Services should reflect on the circumstances of this death and ensure current practices address identified issues and facilitate continuous improvement
Full text
Official source Archived copy

Related cases from VIC

VICcommunity2026-05-07

Finding into death of Elizabeth Susan Edwina Ferris

44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…

Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…

psychiatryintensive carediagnosticcommunicationheroin
VIC2026-04-22

Finding into death of Natasha Stojkoski

38y · Female·Multiple injuries sustained when struck by a train

Natasha Stojkoski, a 38-year-old sales assistant at The Good Guys, sustained a workplace injury in October 2018 involving a Work Assisted Vehicle incident affecting her back, shoulders and neck. Subsequently, she reporte…

psychiatryoccupational and environmental healthsystemcommunicationescitalopram
VIChome2026-04-17

Finding into death of Harrison William Ladd

25y · Male·Combined drug toxicity

Harrison William Ladd, 25, died from combined drug toxicity involving clonazepam, dexamphetamine, codeine, diazepam and pholcodine. He had complex mental health and substance use disorder requiring specialist addiction c…

general practicepsychiatrymedicationcommunicationclonazepam

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.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.