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Adequate services could have prevented deaths of two Adelaide women: Coroner


The Coroner has found that adequate mental health services could have potentially prevented the deaths of two young Adelaide women, and described the State Government’s policy failures in the area as “scandalous”.

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Borderline personality disorder

This morning, the Coroner’s Court handed down the findings of SA deputy coroner Jayne Samia Basheer’s inquest into the death of 22-year-old Miranda Howard in 2013 and the death of another sufferer of borderline personality disorder, 18-year-old Aurora McPherson-Smith, in 2015.

Howard died from complications of an overdose of prescription medication, Basheer found. McPherson-Smith died from multi-organ failure.

In her findings, Basheer argues that it is possible – but not certain – that the deaths of both women could have been prevented if they and their families had had access to adequate services for the treatment of borderline personality disorder.

She also finds that “no psychotherapy or evidence-based treatments were provided to the deceased” during several hospital admissions before Howard’s and McPherson-Smith’s deaths.

Moreover, she finds that the State Government has failed to bring BPD services in up to national standards, and failed to implement any of the recommendations of its own 2014 review into those services.

“I find that neither Miranda Howard nor Aurora McPherson-Smith received enough specialised care,” Basheer finds.

“(And) without urgent changes to the current service delivery for borderline personality disorder in South Australia, patients will continue to be treated in a haphazard, inconsistent and damaging manner and the risk of death, already high due to the nature of this disorder, will continue unabated.”

According to the deputy coroner’s findings: “The ultimate question of whether the deaths of Miranda Howard and Aurora McPherson-Smith could reasonably have been prevented is a complex one.”

However: “If a centralised state-wide service or critical mass of experts had been available to them, their families and their mental health workers, it is possible that the outcome may have been different, particularly I think in Ms Howard’s case.”

“(Howard and McPherson-Smith) and their families reached out to the mental health services … In my opinion, the integrated and consistent advice and care that was needed, and to which the deceased were entitled, was not available to them in South Australia.”

Basheer finds that McPherson-Smith intended to take her own life in June 2015.

A medical professional at the Child and Adolescent Mental Health Services in Mount Barker, Donna Broadhurst, cared for McPherson-Smith between early 2013 and late 2014.

According to Basheer’s findings, Broadhurst “showed an extraordinary level of commitment to her client but she had neither the skills nor the experience to identify the condition, its severity and/or to manage a person with Ms McPherson-Smith’s complex needs”.

“I further find that … Broadhurst had a conflict of interest in seeking to treat both Ms McPherson-Smith and to provide support to her parents.

“The failure to put clear therapeutic boundaries in place with her client and her parents at the outset of treatment fundamentally compromised Ms Broadhurst’s ability to provide effective care.”

In October 2014, senior consultant psychiatrist Dr Cathy Ludbrook took over McPherson-Smith’s care.

Basheer finds that Ludbrook was “well qualified to diagnose and treat a severe presentation of Borderline Personality Disorder” but that her “ability to form a therapeutic relationship with Ms McPherson-Smith was compromised by her ongoing contact with Ms Broadhurst”.

In May 2013, Howard admitted herself to the Fullarton Private Hospital for a planned two-week stay.

Towards the end of that treatment, Johns finds, Howard self-harmed and was sent, “unaccompanied, by the (hospital) in a taxi, together with her prescription medications”.

“Ms Howard absconded from the taxi and subsequently overdosed on these medications.

“For obvious reasons, any practice by the Fullarton Private Hospital of sending high-risk patients for transfer to other hospitals in taxis alone in such circumstances must immediately cease.”

Basheer recommends that the hospital prohibits the transport of any patient who has self-harmed by taxi – or any other chauffeured vehicle – without a nurse or other qualified staff member being present.

She also recommends the State Government urgently implement the recommendations of its own review of BPD services, delivered in 2014.

Basheer writes that the Government has come up with “no reasonable explanation” for its failure to bring BPD services in line with national standards released in 2013 and its failure to implement the recommendations of its own review of those services the following year.

“The State Government has been well aware of the deficiencies in service delivery for Borderline Personality Disorder for a long period of time,” Basheer finds.

“In my opinion it is scandalous that in 2010 the State Government commissioned a high-level group of experts and professionals specifically to assess the adequacy of service delivery in this area and despite receiving comprehensive policy and strategic recommendations in June 2013, none of the recommendations have been implemented.

“Had the State Government acted in a timely manner, in my view, the transition of current services towards a centralised State-wide service for Borderline Personality Disorder, as recommended, would have been well on its way.”

Over the past three years, InDaily has been regularly reporting on the inadequacy of borderline personality disorder services in South Australia and its tragic consequences.

The deputy coroner recommends the Government:

Health Minister Peter Malinauskas told InDaily the Government takes the Coroner’s recommendations seriously and will consider his report in detail.

“We take seriously all recommendations made by the Coroner,” said Malinauskas.

“The State Government has committed to working with people with lived experience of BPD, including Dr Martha Kent, to develop a new model of care and service plan.

“The report will be considered in detail, along with the findings the Coroner has made.”

In September year, the SA Liberal Party committed $10 million to establish a statewide BPD service modelled on interstate experience if it wins the March election.

The following month, the Government matched the pledge.

Malinauskas said the SA Action Plan for People Living with BPD formed “the basis for the South Australian Government’s $10.3 million service to provide access to specialist therapies and supports for people with Borderline Personality Disorder”.

If this article has raised issues for you, you can call LifeLine on 13 11 14 – or you can call the Mental Health Triage Service / Assessment and Crisis Intervention Service on 13 14 65.

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