Inquest into the deaths of TC and SN

Female·Hanging

This finding concerns the deaths of TC, a young mother, and SN, her 17-month-old daughter, who died by hanging on 21 September 2015 in Campsie, NSW. SN had significant life-limiting medical conditions including bilateral micropthalmia (blindness), adrenal insufficiency, hypotonia, and developmental delay. TC became severely depressed following SN's birth, experiencing persistent suicidal and homicidal ideation. Although treated by multiple mental health services and community agencies from November 2014 onwards, TC's care was fragmented and inadequately coordinated across providers. Critically, on 18 September 2015, TC disclosed suicidal and homicidal thoughts to a caseworker, but this disclosure was not properly reported to mental health services or escalated appropriately. TC had been discharged from mental health services in August 2015. On 21 September, TC ended both her own life and SN's life by hanging. The inquest identified significant systemic failures: inadequate inter-agency communication, fragmented case management, poor discharge planning, and failure to escalate TC's disclosures, all contributing to this tragedy.