Finding into death of Catherine Jane Bernard

17y · Female·multiple injuries due to impact by train

A 17-year-old girl with major depressive disorder, a history of self-harm and overdoses, parent-child conflict, and a disclosed history of childhood sexual abuse died by suicide on her first day of Year 12. Critical clinical failures included: (1) Monash Health's failure to report her disclosure of childhood sexual abuse to Child Protection despite mandatory reporting obligations and policies in place; (2) inadequate specialist assessment and treatment of trauma from sexual abuse across mental health services; (3) failure to provide information about specialist sexual assault services; (4) discharge from CAMHS without adequate safety planning or follow-up after Catherine disengaged. While complex psychosocial factors contributed, the coroner found the health service failures represented lost opportunities for earlier specialised intervention, though no direct causal link to her death was established. Improved staff training and access to specialist services for abuse survivors are essential to prevent similar deaths.