Finding into death of Claire Louise Carroll

Contributing factors

• Severe untreated psychotic symptoms at time of death
• Auditory hallucinations and command hallucinations
• Paranoid delusions and persecutory ideation
• History of brother's suicide with known anniversary-related deterioration
• Suboptimal crisis plan inadequately addressing complex mental health presentation
• Premature cessation of evening phone support despite known nighttime distress
• Fragmented and uncoordinated care across multiple services
• Reduced NDIS supports during COVID-19 pandemic with no compensatory care increase
• Heavy reliance on external supports without adequate internal mental health service coordination
• Limited documentation of mental state and risk in clinical records

Coroner's recommendations

1. Implement improved coordination of mental health services through Emergency Services Liaison Meetings or equivalent forums involving police, ambulance, Bellarine CMHC, and Emergency Mental Health services
2. Establish case conferences involving all relevant services to refine crisis plans and clarify roles and responsibilities
3. Develop service delivery frameworks to increase frequency of patient contact and psychiatric reviews
4. Improve internal communication between different Barwon Health mental health services (Bellarine CMHC, psychiatric triage, ED)
5. Enhance clinical documentation of mental state and risk within medical records to support continuity of care
6. Develop crisis plans that adequately address complex presentations, known mental state fluctuations, and frequent after-hours service contacts
7. Establish structured evening support mechanisms for patients known to deteriorate at night while awaiting other supports
8. Coordinate mental health care plans to ensure cohesion between statutory services and external supports such as NDIS