Finding into death of HJE
Deceased
HJE
Demographics
33y, female
Date of death
2014-02-14
Finding date
2017-03-30
Cause of death
Hanging
AI-generated summary
A 33-year-old woman with a history of depression, anxiety, and personality difficulties died by hanging on 14 February 2014, two days after separating from her partner. She had been under the care of a psychiatrist, Dr M., for several years with multiple hospital admissions and referrals to specialist programs including DBT. Her mental health had been significantly affected by a tumultuous relationship characterised by repeated crises, arguments, and breakups. Following the final relationship breakdown on 12 February 2014, she was seen face-to-face on that date but did not disclose suicidal thoughts. Subsequent contact was by text message only. The coroner found that clinical management by Dr M. and The Melbourne Clinic was reasonable and appropriate, with no overt indicators of imminent suicide risk in her final interactions. The coroner highlighted that text-based communication between clinicians and patients limits ability to conduct thorough mental state assessment and recommended patients be informed of crisis service limitations and provided with 24-hour contact details.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- relationship breakdown and separation
- tumultuous relationship with multiple crises and breakups
- depression and anxiety
- personality difficulties manifesting at times of relationship stress and rejection
- alcohol consumption as maladaptive coping strategy
- benzodiazepine use
- Valentine's Day context
- lack of communication from partner following breakup
- intoxication at time of death
Coroner's recommendations
- Health practitioners should recognise that email and text message communications inhibit the ability to conduct thorough mental state and risk assessment as visual and verbal cues are unavailable
- Patients should be informed that private practitioners are not able to provide a crisis service and may not receive text messages, voicemails or emails until the next working day
- Patients should be provided with contact details of appropriate 24-hour crisis services
Full text
Source and disclaimer
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