Finding into death of Finding
Deceased
JF
Demographics
16y, female
Date of death
2013-10-23
Finding date
2016-12-13
Cause of death
mixed drug toxicity (oxycodone, citalopram, fluoxetine and quetiapine)
AI-generated summary
JF, aged 16, died by intentional overdose of prescription medications after being removed from her long-term foster home. JF had a history of depression, borderline personality disorder, reactive attachment disorder, and suicidal ideation. Following escalating behaviour and mental health deterioration, she was placed in residential care (MacKillop) on 17 October 2013, with a Placement Disruption Meeting deciding she remain there for 4-6 weeks. The decision was communicated to JF by telephone on 22 October 2013, causing severe distress. She returned home on 23 October 2013, accessed prescription medications (including oxycodone not prescribed to her) from an unlocked safe, and died under her bed. Key clinical lessons: mental health input should have been sought before placement decisions; face-to-face communication of decisions affecting emotionally fragile adolescents is essential; and therapeutic rather than standard residential facilities are needed for complex cases. The death was not clearly preventable given JF's determination.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- recent loss of close friend to suicide
- boyfriend breakup
- contact between biological mother and other siblings
- placement disruption and removal from foster family
- telephone communication of placement decision rather than face-to-face
- lack of mental health professional input into placement decision
- unfamiliar residential care environment distant from support network
- non-therapeutic nature of MacKillop facility
- access to prescription medications including oxycodone not prescribed to JF
- underlying depression, borderline personality disorder, reactive attachment disorder
Coroner's recommendations
- In the event of the death of a child under its care, the Department of Health and Human Services should consider including any agency contracted to care for that child in its internal review process and distribution of its report to that agency.
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