Finding into death of JV M
Deceased
JVM
Demographics
19y, female
Date of death
2022-04-13
Finding date
2025-07-03
Cause of death
multiple injuries sustained in a train incident
AI-generated summary
JVM was a 19-year-old with major depressive disorder, anxiety, and possible first-episode psychosis who died by suicide after jumping in front of a train. She had multiple psychiatric admissions and was under care of St Vincent's Hospital Mental Health Service (SVHM) in the week before her death. Key issues identified: inadequate engagement with family despite their expressed concerns about escalating suicidal ideation; incomplete safety planning that did not meet clinical guidelines; possible misdiagnosis of borderline personality disorder rather than psychosis; and insufficient information provided to family about warning signs and coping strategies. The coroner found deficiencies in care but could not conclude these directly caused her death. SVHM has implemented recommendations addressing risk assessment documentation, carer engagement, and post-discharge review processes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- self-cessation of psychiatric medications
- declining mental health and progressive depression
- inadequate family engagement by treating clinicians
- incomplete safety planning
- poor rapport between patient and treating team
- patient's guarded presentation and withholding of risk information
- possible diagnostic uncertainty regarding psychotic symptoms versus borderline personality disorder
- stress related to accommodation decisions and relationship breakdown
- COVID-19 isolation contributing to mental health decline
Coroner's recommendations
- Implement a standardised risk assessment and management template for use in the Emergency Department and CATT which is fit for purpose for every assessment
- Ensure that the best practice principle to engage carers separately to consumers, to ensure they can speak freely, is included in orientation as part of an interactive session led by the lived experience workforce
- Establish a process for the routine review of all risk assessment and management plans for EDMH and CATT discharges from the service within the prior 72 hours, and when possible incorporate lived experience
- Standardise formal documentation of clinical reviews in Medical Records Online (MRO)
- Develop a standard contact details information sheet which can be included as part of the printed risk management plan and given to all consumers, which includes contact details and escalation pathways for the health service and external support services within the local area
- Review the Guidelines for Integrated suicide-related crisis and follow-up care in Emergency Departments and other acute settings, identify where there are opportunities to enhance practice, and implement change
- Review opportunities to strengthen and support the process and documentation of risk assessments provided by the on-call Consultant Psychiatrists
- Support ongoing work of the Victorian Government to implement recommendations from the Royal Commission into Victoria's Mental Health System
- Pursue opportunities to expedite implementation of the Zero Suicide Framework across the mental health and wellbeing sector
Full text
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