Inquest into the death of XY

17y · Female·multiple blunt force injuries after being struck by a train

17-year-old X died by suicide on 18 December 2012 after being struck by a train. She received multiple psychiatric admissions and CAMHS outpatient care from July-December 2012 for suicidal ideation, overdose attempts, and depression. The Coroner found that care provided by Hornsby Hospital and CAMHS was appropriate and compliant with NSW Health policies. Staff made reasonable decisions regarding discharge on 17 December 2012 following a reported overdose; she denied suicidal intent but disclosed concerning behaviours after discharge. The final decision not to readmit was considered reasonable given available information. Expert evidence supported the care provided. No clinical errors were identified, though improved communication about hospital discharge procedures and adolescent inpatient facility eligibility criteria were recommended.