Finding into death of Ms P

30y · Female·Multi organ failure from hydrochloric acid ingestion

Ms P, a 30-year-old woman with recent-onset depression and anxiety, died from multi-organ failure following intentional hydrochloric acid ingestion on 22 September 2008. She had presented to mental health services on 18 September following suicidal ideation and overdose of benzodiazepines. Despite hospitalization, she was discharged to community care after one night based on her denial of suicidal intent, which masked significant clinical deterioration. Critical failures included fragmentation of care across three different community mental health teams within three days, incomplete information transfer between services, absence of psychiatric assessment, and lack of coordination with her treating psychologist. The coroner found the death possibly preventable, stating that unified community team management with complete clinical information might have identified her true risk and enabled hospitalization. Child protection concerns were also entirely disregarded.