Inquest into the Death of Child SK (Name Subject to Suppression Order)
Deceased
Child SK
Demographics
13y, female
Date of death
2020-07-23
Finding date
2024-04-08
Cause of death
complications of a head injury sustained when she deliberately stepped in front of an oncoming car
AI-generated summary
A 13-year-old with emerging emotionally unstable personality disorder (EUPD) died by suicide after deliberately stepping in front of a car on 21 July 2020, two days after a positive appointment with mental health clinicians. In the final 6 weeks before death, she had 8 ED attendances and 6 hospital admissions to the mental health unit. Critical gaps were identified: the Department of Communities failed to adequately assess referrals for family support services and delayed action; Bentley Family Clinic provided appropriate community care despite fragmentation from repeated hospital admissions and the patient's initial treatment reluctance; Perth Children's Hospital appropriately managed acute presentations but faced a significant service gap—there was no step-up/step-down facility available between discharge and community intensive programs like Touchstone, forcing unsafe rapid discharges to parents at breaking point. Long hospital stays are contraindicated in EUPD treatment. The coroner emphasised that intensive day programs and acute community response teams, combined with dedicated step-down facilities for under-16s, are essential to prevent similar deaths.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- emerging emotionally unstable personality disorder with chronic suicidal ideation and high impulsivity
- insufficient step-down/step-up residential facilities for children under 16 years with complex mental health conditions
- absence of intensive community-based crisis support services available at the time
- rapid repeated hospital discharges without adequate community-based infrastructure to support safe transition
- parents unable to safely contain child's self-harm impulses at home despite protective efforts
- delay in Department of Communities assessment and referral to family support services
- fragmentation of care due to frequent hospital admissions disrupting therapeutic relationships
- lack of alternative treatment options between hospital admission and community-based Touchstone program
Coroner's recommendations
- Funding be provided to the Mental Health Commission to establish a permanent network of Acute Care and Response Teams (ACRT) or suitable equivalent models throughout the remainder of Western Australia, including regional areas, operating on the model of the Perth metropolitan services.
- Funding be provided to the Mental Health Commission for a step-up/step-down facility with an intensive day program for children and young people under 16 years with complex mental health conditions, using a hybrid model incorporating the best features of the now-closed Transition Unit and current Touchstone program to provide an easily accessible service and alternative to hospitalisation.
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