Finding into death of KJ

18y · Female·Multiple injuries due to impact by train

KJ was an 18-year-old girl who died by suicide by train on 30 November 2012, six months after a suicide attempt. She had a complex trauma history, including childhood sexual abuse aged 6, and subsequently developed depression, self-harm, and suicidal ideation. Critical clinical lessons: (1) KJ was discharged from mental health services on 5 November 2012 despite ongoing high suicide risk, multiple recent overdoses, and active hallucinations of her attacker; (2) she was not registered with the Victims Register despite being entitled, meaning she received false information that her attacker would be released in 2013 (he had actually died in custody in 2007); (3) there was inadequate coordination between multiple mental health services; (4) her GP saw her on the day of death and noted active suicidal ideation but only arranged a two-week follow-up. Earlier robust risk assessment, sustained crisis support, and information about her attacker's actual death might have prevented this tragedy.