Finding into death of J H
Deceased
JH
Demographics
15y, male
Date of death
2019-09-16
Finding date
2023-10-17
Cause of death
Electrocution
AI-generated summary
JH, a 15-year-old with Autism Spectrum Disorder and Major Depressive Disorder, died by electrocution at home on 16 September 2019. He had been experiencing suicidal ideation for months and was discharged from inpatient psychiatric care (Stepping Stones) on 19 August 2019 after a paracetamol overdose. Community mental health follow-up appeared appropriate with regular appointments and safety planning. However, significant Child Protection concerns were inadequately managed: practitioners failed to assess cumulative harm from 16 prior notifications, did not adequately investigate the mother's known alcohol abuse and history of violence towards children, relied on a child's report rather than direct assessment, and did not ensure community supports were in place at case closure. The coroner found no causal connection between these failures and the death, but identified systemic gaps in Child Protection's assessment of risk, cumulative harm consideration, and family support linkage.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Major Depressive Disorder with chronic suicidal ideation
- Autism Spectrum Disorder
- Exposure to family violence and parental conflict
- Maternal alcohol abuse
- Maternal physical and verbal violence
- Inadequate Child Protection assessment and support
- Failure to assess cumulative harm
- Psychosocial stressors
- Diagnostic uncertainty regarding possible psychotic illness
Coroner's recommendations
- Child Protection to strengthen practice in assessing cumulative harm by considering new reports in the context of historical concerns rather than episodically
- Child Protection to ensure adequate direct assessment of parental substance abuse and mental health rather than relying on child reports
- Child Protection to explore child safety comprehensively when returning to previously concerning caregivers
- Child Protection to ensure family linkage with ongoing community-based support services at case closure
- Child Protection to strengthen training and practice resources including use of 'My Views' booklets to capture child voice
- Implementation of MARAM (Family Violence Multi-Agency Risk Assessment and Management Framework) with trauma-informed practice
- Implementation of SAFER Children Framework and professional judgment training for all practitioners
- Mandatory training for Child Protection staff on working with adolescents, children with disabilities, and cumulative harm assessment
- Area-based collaboration improvements with key stakeholder agencies including embedded family violence specialist practitioners
Full text
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