Finding into death of J H

15y · Male·Electrocution

JH, a 15-year-old with Autism Spectrum Disorder and Major Depressive Disorder, died by electrocution at home on 16 September 2019. He had been experiencing suicidal ideation for months and was discharged from inpatient psychiatric care (Stepping Stones) on 19 August 2019 after a paracetamol overdose. Community mental health follow-up appeared appropriate with regular appointments and safety planning. However, significant Child Protection concerns were inadequately managed: practitioners failed to assess cumulative harm from 16 prior notifications, did not adequately investigate the mother's known alcohol abuse and history of violence towards children, relied on a child's report rather than direct assessment, and did not ensure community supports were in place at case closure. The coroner found no causal connection between these failures and the death, but identified systemic gaps in Child Protection's assessment of risk, cumulative harm consideration, and family support linkage.