Finding into death of Rachel Naomi Mihail

AI-generated summary

Rachel Mihail, a 36-year-old with a complex psychiatric history including PTSD, depression, anxiety, and agoraphobia, ingested liquid nicotine at home on 22 November 2017 after calling mental health triage expressing suicidal intent. The clinical lessons relate to the response to acute suicide risk. At 1:10am, Ms Mihail disclosed to mental health clinician Rachel Finch that she had researched suicide and planned to overdose on liquid nicotine, then ended the call. Ms Finch arranged a police welfare check but not an ambulance, believing the overdose had not yet occurred. Victoria Police were tasked at 1:23am but did not arrive until 1:48am—a 25-minute delay during which Ms Mihail ingested the nicotine and called 000 at 1:34am in severe distress. Paramedics arrived at 1:52am but resuscitation was unsuccessful. The coroner found no evidence that timely police response would have prevented death, but criticised the lack of urgency in the police response and the mental health triage decision not to request immediate ambulance dispatch. Key clinical lesson: mental health staff must ensure emergency ambulance response for imminent suicide risk with access to lethal means, not rely on police welfare checks alone.

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