Inquest into the death of Fiona Goodberg

Case Number: 2020/310753

Date of Findings: 24 October 2024

Magistrate: Deputy State Coroner, Derek Lee

CORONIAL LAW – manner of death, intentionally self-inflicted death, mental health diagnosis, mental health assessment, subacute mental health care, postpartum psychosis, obsessive compulsive disorder, delusions, coordination of care, collection of collateral information, referral to inpatient mental health unit, handover of care, involuntary detainment, Mental Health Act, discharge planning, adequacy of Mental Health Line, third party triage, referral to community mental health team, mental health intervention, Mother-Baby Unit, Motilium, SAFE START

Responses

Recommendations

To the Deputy Secretary, Health System Strategy and Patient Experience, NSW Health

1. I recommend that consideration be given to whether the current capacity of Mother/Parent-Baby Units in NSW is sufficient to meet the needs of prospective inpatients from both metropolitan and regional areas. 

To the Deputy Secretary, Health System Strategy and Patient Experience, NSW Health and CEO of Nepean Blue Mountains Local Health District

2. I recommend that there be investigation and consideration of the advantages and disadvantages of direct referral from public and private inpatient mental health units to community mental health teams without the need for triage through the Mental Health Line.

3. I recommend that consideration be given to whether appropriate safeguards exist, and whether sufficient guidance is provided to clinicians, to overcome the fragmentation of care that can occur when a mental health consumer is receiving treatment from different health care providers, and within both the private and public health care sectors, without having a single clinician responsible for coordinating such care. 

To the CEO of St John of God Burwood Hospital

4. I recommend that consideration be given to whether any existing policies and procedures regarding the obtaining of collateral information about an inpatient from a referring clinician should impose a stricter timeframe and if so, what clinical indicators warrant the imposition of such stricter timeframes.

To the Commissioner of NSW Police Force

5. I recommend that consideration be given to whether New South Wales Police Officers have adequate training to:

a) apply the provisions of the NSWPF Handbook regarding alternative options for mental health intervention, including how such options might be employed and in what circumstances; and

b) respond appropriately to a concern for welfare report regarding a person's mental health status.