Inquest into the death of AB (429/09)

Female·Exsanguination following self-infliction of a wound with the intention of taking her own life

A woman with a long-standing history of mental health issues and previous suicide attempts (May 2008, September 2007, April 2008) died on 13 February 2009 from exsanguination due to a self-inflicted wound in bushland near Kenthurst, NSW. She had recently been discharged from private hospital care and was awaiting admission to a dialectical behavioral therapy program. Following family notification of her expressed intent to self-harm, police rapidly initiated a search operation. The coroner found that police acted appropriately given her documented mental health history and previous risk. No clinical failures were identified. The inquest was mandatory due to the connection with a police search operation. The coroner recommended improved police officer education regarding mobile phone triangulation and last-call details in missing-person investigations.