Finding into death of Mikael Chandra Rohan

14y · Male·head injuries when struck by a train

Mikael Rohan, a 14-year-old with a history of separation anxiety, attachment disorder, and sleep disturbance, died after stepping in front of a train on 16 November 2010. He had recently been distressed about a reported pregnancy with a girlfriend and experienced a rapid deterioration following his girlfriend ending their relationship. His presentation to Monash on 9 November 2010 with suicidal ideation was assessed by a psychiatric nurse (Nurse Sebille) rather than a child and adolescent psychiatrist as requested by his GP. The assessment was rated as low risk and discharged. Care became fragmented when Dr O.'s treatment was terminated in favour of Headspace counselling. Clinicians did not utilise adequate senior psychiatric review of an adolescent in crisis. The coroner noted that terminating the established therapeutic relationship with Dr O. may have removed a stabilising influence during a high-risk period, though acknowledged the complexity of predicting suicide risk in adolescents.