Inquest into the death of Grace HERINGTON

23y · Female·multiple blunt force injuries from fall from height

Grace Herington, 23, died from multiple blunt force injuries sustained in a fall from a highway off-ramp during an acute psychotic episode induced by cannabis use. She had attended Royal North Shore Hospital the previous day for mental health assessment and was discharged after evaluation by a mental health nurse and psychiatrist who considered her low risk. Key clinical lessons include: (1) the importance of obtaining collateral information from family members when assessing acute mental health presentations, as Grace minimised symptoms and family knew of bizarre delusions suggesting psychosis; (2) recognising that cannabis-induced psychosis can present acutely and unpredictably; (3) the challenge of balancing patient autonomy with safety when patients decline family involvement; (4) ensuring ambulance handover documentation reaches clinical staff; (5) follow-up protocols when voluntary patients leave ED before discharge. The coroner found the hospital assessment was of good quality by an experienced clinician, though family information might have clarified the degree of thought disorder. Police response was appropriate given circumstances.