Finding into death of J Y
Deceased
JY
Demographics
24y, female
Date of death
2013-07-01
Finding date
2019-06-06
Cause of death
injuries sustained in descent from height
AI-generated summary
A 24-year-old woman with intellectual disability and borderline personality disorder died from injuries sustained in descent from height from a sixth-floor balcony. She had threatened suicide from the same balcony on 8 March 2013 and was admitted to Upton House under mental health assessment. A critical finding was that the 8 March balcony incident was not communicated to DHHS, her family, her case manager, or other involved parties including her GP and support workers. Had this information been shared, a risk assessment of her accommodation would likely have been undertaken. The coroner found no fault in her mental health care or discharge planning. The main issues identified were: failure of information transfer between Eastern Health and other parties, the inappropriateness of family violence intervention orders for persons with cognitive impairment who cannot understand their conditions, and potential confusion among clinical staff regarding privacy law exceptions for patients at serious risk.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- failure to communicate 8 March 2013 balcony incident to DHHS, family, and other parties involved in care
- intellectually disabled person subject to family violence intervention order she could not understand or comply with
- incarceration in June 2013 followed by distressed behaviour and aggression
- cognitive impairment affecting understanding of intervention order conditions and consequences
- lack of regular multidisciplinary meetings to coordinate care
- unclear information sharing protocols regarding patient at risk of serious harm despite privacy law exceptions
Coroner's recommendations
- The Attorney General should review the Family Violence Protection Act 2008 and consider including provisions similar to sections 61 and 35 of the Personal Safety Intervention Order Act 2010 to require courts to consider whether respondents with cognitive impairment can understand and comply with intervention order conditions
- The Department of Health and Human Services, in consultation with primary care networks, public hospitals, and disability services, should develop a code of practice to implement a notice system that notifies appropriate organisations and individuals of presentations or admissions related to self-harm or high-risk behaviour where the individual has cognitive impairment, is receiving support services from DHHS or NDIS, or is under guardianship orders
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