Finding into death of Ms YPM

27y · Female·Hanging

Ms YPM, a 27-year-old woman with a long history of borderline personality traits, depression, anxiety and eating disorder, died by hanging on 17 May 2020. In the preceding two weeks, she presented to Alfred Hospital following a polypharmacy overdose on 9 May, was briefly admitted to The Melbourne Clinic on 11-12 May after disclosing suicidal ideation and making an apparent suicide attempt (tying a scarf), then was discharged after just over 24 hours despite concerning recent behaviours. While the coroner found no evidence that clinicians erred in determining she did not meet criteria for compulsory treatment under mental health legislation, deficiencies were identified in communication and discharge planning. Key clinical lessons: (1) more robust discussions with patients about family involvement in care are essential when discharge planning depends on family support; (2) timely handover of care between services (Alfred to private psychiatrist) is critical; (3) discharge summaries should routinely be provided to community-based psychologists involved in ongoing care; (4) collateral information should be sought when patients present with acute risks; (5) risk formulation for patients with borderline personality traits requires nuanced assessment balancing autonomy, therapeutic risk-taking, and family involvement.