Finding into death of Maggie Rose Bant
Deceased
Maggie Rose Bant
Demographics
20y, female
Date of death
2019-05-31
Finding date
2020-12-09
Cause of death
Plastic bag asphyxia with inhalation of helium
AI-generated summary
A 20-year-old woman with a history of depression, anxiety, and self-harm died by helium inhalation asphyxia. She had been treated by her GP with antidepressants and mental health referral to a psychologist but never disclosed suicidal ideation despite clinical concerns. Her ex-partner's mother observed concerning behaviour and believed suicide was inevitable given her mental health severity. The coroner identified her death as part of a statistical suicide cluster in Mildura, emphasising easy public access to helium gas as a critical factor. Key clinical lessons: inadequate assessment of suicide risk despite presenting concerns, limited documentation of mental health severity, and failure of informal supporters to escalate concerns through formal mental health channels. The ease of helium access and lack of regulatory controls remain unresolved public health issues.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Mental health deterioration with depression and anxiety
- History of self-harm and suicidality
- Easy public access to helium gas cylinders
- Recent relationship separation
- Failure to detect or act on suicide risk despite clinical presentation
- Lack of comprehensive suicide risk assessment by GP
- Uncertain medication compliance
- Withdrawal and taciturn behaviour noted by family but not adequately escalated
Full text
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