Finding into death of Danielle Julie Kaye Thomson
Deceased
Danielle Julie Kaye Thomson
Demographics
41y, female
Date of death
2022-11-04
Finding date
2024-10-07
Cause of death
Neck compression and hanging
AI-generated summary
Danielle Thomson, a 41-year-old woman with complex medical and mental health conditions including cervical dystonia, bipolar disorder, borderline personality disorder, chronic pain, and alcohol use disorder, died by suicide on 4 November 2022. She presented to Ballarat Hospital ED with severe neck pain and anxiety about her condition while in a residential rehabilitation program at Windana. Triaged as Category 3 (semi-urgent), she waited in the ED but left before being seen, approximately 3 hours after arrival. She subsequently obtained an electrical cord and died by hanging. Expert review found care at the Geelong Clinic, Windana, and Ballarat Hospital to be generally reasonable. Key clinical lessons include: the high suicide risk in patients with concurrent chronic pain, mental illness, and substance abuse; the importance of integrated multidisciplinary care for this complex population; and recognition of the 'catch-22' that such patients often do not respond effectively to treatment until mental state is stabilised. The coroner identified no specific medical errors but highlighted systemic issues around integrated care coordination.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- chronic pain (cervical dystonia)
- bipolar affective disorder
- borderline personality disorder
- depression and anxiety
- alcohol use disorder
- feelings of hopelessness regarding permanent nature of physical condition
- prolonged wait in ED without being seen
- ED access block
- inadequate integrated care coordination across services
- lack of family involvement in treatment planning
Coroner's recommendations
- The Suicide Prevention and Response Office of the Department of Health examine the relationship between chronic pain, mental illness, substance abuse and suicide to identify strategies to address the clinical dilemma facing clinicians treating people who experience chronic pain along with mental illness and substance abuse who often do not respond effectively to treatment of their chronic pain.
- The Suicide Prevention and Response Office liaise with the Commonwealth Department of Health and Aged Care regarding the National Strategic Action Plan for Pain Management to identify areas of mutual interest concerning the relationship between chronic pain, mental illness, substance abuse and suicide.
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —