Finding into death of GM

Female·Fulminant hepatic failure due to paracetamol toxicity

A 19-year-old female with anorexia nervosa, borderline personality disorder, and chronic suicidality was admitted to St Vincent’s psychiatric inpatient unit on 28 July 2023. She reported ongoing suicidal thoughts but engaged well in safety planning and showed improvement during overnight leave 5–6 August. On 8 August, she was discharged on overnight leave and the following day ingested a large quantity of paracetamol purchased from a local service station. She presented with fulminant hepatic failure and despite transfer to the Austin Hospital ICU for potential liver transplantation, died on 22 August 2023. The coronial review found no specific clinical opportunities for prevention; psychiatric admission management appeared reasonable with appropriate risk assessment, family involvement, and community service coordination. The coroner noted the inherent tension between containing chronically suicidal patients and supporting community-based intensive mental health management.