Inquest into the death of Pamuk RONA

53y · Female·unascertained natural causes

Ms Rona, a 53-year-old woman with major depression, was admitted involuntarily to Bungarabee House psychiatric unit on 6 August 2018 after presenting with catatonic features, mutism, and refusal to eat or drink. She was found unresponsive the following afternoon and died shortly after. Autopsy was inconclusive. The coroner found the psychiatric assessment appropriate, diagnoses reasonable, and management plan consistent with guidelines. An independent psychiatrist found no missed opportunities. Death cause remained undetermined. The case highlights the challenges of managing catatonia in psychiatric settings. Post-incident, the health service implemented improvements including formal training on catatonia recognition and escalation procedures, formalised lorazepam availability for parenteral administration, and consumer wellness planning for relapse prevention. The coroner commended these changes, finding no recommendations necessary.