Inquest into the Death of Radinka MIHAJLOVIC
Deceased
Radinka MIHAJLOVIC
Demographics
47y, female
Date of death
2012-05-01
Finding date
2017-01-05
Cause of death
Multiple injuries from being struck by a train; death determined to be suicide
AI-generated summary
A 47-year-old woman with bipolar affective disorder and PTSD, originally from Bosnia, died by suicide by stepping in front of a train on 1 May 2012. She was subject to a Community Treatment Order at the time. Critical clinical lessons include: (1) discharge planning from inpatient psychiatric care was inadequate, with serious miscommunications between Swan Valley Centre and Inner City Community Mental Health Service about whether depot olanzapine would be provided; (2) there was no coordinated multidisciplinary discharge conference despite known medication non-compliance; (3) the patient went unmedicated for weeks after CTO implementation despite being placed on the order specifically for non-compliance; (4) communication between public and private mental health systems broke down, with ICCMHS unaware the patient's concerns about side effects were so severe she later expressed suicidal ideation; (5) cultural and language barriers were not adequately addressed despite the patient responding better to practitioners fluent in her native language. On 1 May 2012, after receiving her first depot injection, the patient presented to her private psychiatrist extremely distressed with suicidal thoughts. His attempts to arrange voluntary hospital admission via ICCMHS resulted in mutual distrust between providers. The patient was assessed as low risk and discharged home, then died by suicide hours later.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Inadequate discharge planning from Swan Valley Centre
- Miscommunication between Swan Valley Centre and ICCMHS regarding depot medication plan
- Patient left unmedicated for weeks after CTO implementation despite placement on order for non-compliance
- Breakdown in communication between public and private mental health systems
- ICCMHS unaware of severity of patient's distress and suicidal ideation
- Absence of coordinated multidisciplinary discharge conference
- Inadequate consideration of cultural and language barriers
- Assessment of low suicide risk that missed escalating clinical deterioration
- Patient discharged to community home instead of voluntary hospital admission when expressing active suicidal ideation
Coroner's recommendations
- Patients with mental health issues requiring treatment in public or private systems should be provided with a community liaison person (coordinator) who understands the treatment/management plan and can ensure proper coordination between all relevant facilities and practitioners
- Discharge planning from a facility or referral between mental health practitioners should always include the nominated community liaison person in person at any conference when the patient and their community carers are present to ensure understanding and continuity of management
- Patient confidentiality should not include the fact of treatment and management as between a community liaison person and other mental health practitioners, only the content of private disclosures
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