Finding into death of Ms YPM

Contributing factors

• long-standing borderline personality traits and major depressive disorder
• chronic suicidal ideation
• recent polypharmacy overdose
• recent apparent suicide attempt (scarf incident) in hospital
• self-cessation of psychiatric medications three weeks prior
• recent relationship breakdown
• work-related stressors and reduced hours due to COVID-19
• alcohol and illicit substance use (cocaine, ketamine, MDMA detected post-mortem)
• inadequate family involvement in discharge planning
• deficient communication between treating clinicians
• limited duration of inpatient admission
• intoxication at time of death affecting judgment

Coroner's recommendations

1. To the Chief Psychiatrist and Alfred Health: Consider the feasibility of routinely providing private psychologists involved in a patient's care as part of a long-standing community-based treating team, and who are nominated in the emergency department/short stay discharge plan to provide community follow-up, with a timely copy of the discharge summary.
2. To The Melbourne Clinic: Work with admitting private psychiatrists to consider the feasibility of routinely providing private psychologists involved in a patient's care as part of a long-standing community-based treating team, and who are nominated in the discharge plan to provide community follow-up with a timely (same day) copy of the discharge summary.
3. To The Melbourne Clinic: Develop and circulate to all staff and Visiting Medical Officers (VMOs) a clear policy or practice guide on who is responsible (e.g. clinical staff or VMOs) for provision of discharge summaries to treating practitioners in the community.