official inquest for suicide Michaela Mundy

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official inquest for suicide Michaela Mundy

Post by redpill on Tue Sep 22, 2015 11:03 pm

15 year old Michaela Mundy committed suicide pictured below



there was an inquest into her suicide
cite

Suicide of teen Michaela Mundy throws spotlight on failures of state mental health system
THE suicide of teenager Michaela Mundy has exposed fundamental flaws in the state's mental health system that must be addressed, the Coroner has found.

State Coroner Mark Johns today handed down his findings into Ms Mundy's death on July 9, 2012.

In the document, Mr Johns says Ms Mundy and her family did not receive the level of service they needed from the Child and Adolescent Mental Health Service when they sought its help.

He said CAMHS must be restructured to ensure the errors that contributed to Ms Mundy's death did not occur again.

Mr Johns said the service urgently required more psychiatrists - the lack of which served as a "disincentive" to those desperately needing help.

"Social workers are no doubt very useful in dealing with the mildest of depression cases," Mr Johns said.
News
Suicide of teen Michaela Mundy throws spotlight on failures of state mental health system

   Chief Court Reporter Sean Fewster
   The Advertiser
   March 12, 2014 5:52PM

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Adelaide Afternoon Newsbyte March 12
Adelaide Afternoon Newsbyte March 12
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THE suicide of teenager Michaela Mundy has exposed fundamental flaws in the state's mental health system that must be addressed, the Coroner has found.

State Coroner Mark Johns today handed down his findings into Ms Mundy's death on July 9, 2012.

In the document, Mr Johns says Ms Mundy and her family did not receive the level of service they needed from the Child and Adolescent Mental Health Service when they sought its help.

He said CAMHS must be restructured to ensure the errors that contributed to Ms Mundy's death did not occur again.

Mr Johns said the service urgently required more psychiatrists - the lack of which served as a "disincentive" to those desperately needing help.

"Social workers are no doubt very useful in dealing with the mildest of depression cases," Mr Johns said.
Michaela “Mikki” Mundy, who died in July 2012. Source: the King family.

Michaela "Mikki" Mundy, who died in July 2012. Source: the King family.

"However, the current approach where there (are) many social workers (and) less than half of a psychiatrist for 220 to 250 patients is inappropriate.

"Forty per cent of a psychiatric position cannot possibly see more than a small percentage of those 200 to 250 patients."

Outside court, Ms Mundy's mother, Ingrid King, called on both major parties in the Saturday's State Election to prioritise an upgrade of mental health services for all people, regardless of age.

"Unfortunately it always comes down to money," Ms King said.

"Unlike the road toll, there's no money for the government to make in this, there's no campaign."My message is we need to have a really thorough, close look at what is going on in the mental health system and what's happening with our young people, and other people, who are taking their lives every day."

In September last year, Mr Johns began hearing an inquest into the death of the Seymour College student .

He heard Ms Mundy, 15, had moved between her parents' homes and boarding school, experiencing loss of appetite, depressed thoughts and an incident of self-harm.

Child and Adolescent Mental Health services staff, however, assessed her as being at "low to moderate" risk.Ms Mundy and Ms King went on to consult with Stirling GP Dr Jason Garrood, who mistakenly believed she had already seen a psychiatrist.

When he sought CAMHS' aid, the body said it could not assess Michaela and recommended he teach her "self-soothing and calming techniques".

Dr Garrood halved Michaela's antidepressant dosage after a fainting spell but, after she expressed suicidal thoughts, increased it - she died four days later.

During the inquest, CAMHS worker Vina Hotich, who assessed Michaela, broke down saying she could - and should - have done more to help the teen .

In his findings, Mr Johns praised the staff of Seymour College, saying they had done all they could to provide Ms Mundy with pastoral care.He said Dr Garrood - who, since Ms Mundy's death, has ceased treating adolescents and women under 21 - had been placed in a difficult situation by CAMHS.

Mr Johns cited a psychiatrists' review of Ms Mundy's case, which concluded CAMHS should have acted sooner to treat her early signs of depression.

He said that report made it clear Ms Hotich and her superiors had held "too rigidly" to CAMHS guidelines which insist the organisation must have sole care of a patient.

"In my opinion CAMHS failed to provide an adequate service to Michaela Mundy," he said.

"Although CAMHS is a multidisciplinary structure, Ms Hotich was not operating that way (but) was actually doing what was expected of her in this respect."In my opinion the whole point of being part of a multidisciplinary team was defeated by this mode of operation."

He said Ms Hotich should have referred Ms Mundy to a psychiatrist and involved her father in her treatment, despite the objections of Ms Mundy and Ms King.

"The fact of the matter is that Mr Mundy had important information to impart which only became known during his evidence at inquest," he said.

Mr Johns said CAMHS should have "sought to re-engage" with Ms Mundy after she severed contact and went to Dr Garrood.

"By the time she was seen by Dr Garrood, she had severe major depression," he said.

"Had her condition been properly treated earlier, Michaela would have had a better chance of not proceeding to severe major depression, and would have had a better chance of recovering."

Mr Johns recommended Jack Snelling, the Minister for Mental Heath and Substance Abuse, restructure CAMHS.

He said everything the organisation does should be carried out under the supervision of psychiatrists, not left to social workers acting alone.

"All services provided by CAMHS should be provided under the same level of consultant supervision as a surgical service in a public hospital," he said.

"To be absolutely clear, I refer to supervision by a consultant psychiatrist."

Mr Snelling said he took the Coroner's recommendations very seriously.

"One of the first things I'll do in a re-elected government will be to refer the Coroner's report to our new mental health commissioner to get some expert advice on whether CAMHS would lend itself to a more hierarchical structure and whether that would better serve the needs of young people," he said.

Mr Snelling said CAMHS workers did extraordinarily difficult work and he was very confident that there are many lives saved every year because of the intervention of CAMHS workers.

"I think in the past there has been an attitude that (youth suicide is) something best not talked about," he said.

"But I think we're slowly coming around to the realisation that youth suicide is something that we do need to talk about, that we do need to bring out into the open.

"We've got more chance of preventing it if it is a subject which is openly acknowledged and talked about, so I would certainly welcome any moves for us to draw more attention to the issue."

Outside court, Ms King said the sole "good thing" to come from her daughter's death was the coronial findings.

"I just hope that by what's happened, and by this coming out, that we can make some positive changes for mental health services and prevent this from happening again," she said.

"There are lots of flaws in the system and we need to become more vigilant.

"There need to be more services, and families need to know exactly where to go when a loved one is suffering and needs help."

Ms King said she wanted Miss Mundy to be remembered as "an artistic, beautiful girl" who dreamt of becoming an actor.

"Unfortunately that has been cut short and we will never know what the future held for her," she said.

In a statement, Seymour College principal Anne Johnstone paid tribute to Miss Mundy and "once again" offered condolences to her family.

She said the school was heartened by Mr Johns' findings that its staff had gone "above and beyond" in their care for Miss Mundy.

"The findings reinforce that depression and youth suicide are serious issues and ones about which everyone must remain particularly vigilant and responsive," she said.

this is a link
link to pdf

below is about 10 pages of the report, it is too long to fit on this post

it shows some of the thoughts that go into mental health and suicide. for some this is alien Territory


CORONERS ACT, 2003
SOUTH AUSTRALIA
FINDING OF INQUEST

An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 3rd, 4th, 5th and 6th days of September 2013, the 10th, 11th, 12th and 13th days of December 2013 and the 12th day of March 2014, by the

Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Michaela Jayne Mundy.

The said Court finds that Michaela Jayne Mundy aged 15 years, late of 28 High Street, Echunga, South Australia died at Echunga, South Australia on the 9th day of July 2012 as a result of neck compression due to hanging. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death


1.1. Michaela Jayne Mundy died on 9 July 2012. She was aged 15 years. An autopsy was performed by Dr Karen Heath, forensic pathologist, who reported1 that the cause of death was neck compression due to hanging, and I so find. Dr Heath reported that analysis of blood obtained at autopsy showed a therapeutic concentration of the antidepressant medication, fluoxetine.

2. Background


2.1. Michaela Mundy was born in August 1996. She was the first child of Michael and Ingrid. When she was 6 years of age her parents separated. Both parents subsequently remarried and had further children. Michaela initially lived with her mother. This continued until 2007 when her mother gave birth to a half sister following which her mother suffered from post-natal depression. As a result of that

1 Exhibit C2a

2


Michaela went to live with her father and stayed a few nights per week with her mother. This arrangement was in place until 2011 when Michaela’s father changed employment and was required to fly to Sydney regularly for contract work. From this time Michaela’s living arrangements were less structured than previously. From sometime in 2010 Michaela’s mother noted that Michaela was displaying symptoms of depression including lethargy and loss of appetite. She told her mother that she was feeling depressed. Her mother contacted the Child and Adolescent Mental Health Service (CAMHS) in June 2011.

2.2. Michaela was a student of Seymour College. The costs associated with her attendance at that school were met by her father. Her father was not made aware by either Michaela or her mother of her attendance at CAMHS.

3. Michaela attends Child and Adolescent Mental Health Service


3.1. Michaela’s dealings with the Child and Adolescent Mental Health Service are best described through the evidence of the only person at that service with whom she had any contact, Ms Vina Hotich. Ms Hotich gave evidence at the Inquest. She described herself as one of the therapists at Mount Barker CAMHS and said that she was a social worker by qualification. She had commenced employment with CAMHS in September 2010 and said that her role was to provide therapeutic psychological services to children2. She said that Southern CAMHS (and I understand CAMHS generally) is a multi-disciplinary service. The bulk of the people who work at CAMHS as clinicians are psychologists and social workers. Mount Barker CAMHS also had the services on a part-time basis of a child psychiatrist3.

3.2. Ms Hotich’s first session with Michaela took place on 8 July 2011. Ms Hotich said that in that first session she spent most of her time talking to Michaela’s mother before spending a relatively short amount of time with Michaela. Michaela’s mother informed Ms Hotich that Michaela had cut her wrist and arms approximately two months prior to that first visit4. She also informed Ms Hotich that Michaela had been seen by a general practitioner and by a counsellor. She reported that the general practitioner had agreed that Michaela might be suffering from depression. Michaela’s mother told Ms Hotich that she (the mother) had suffered from post-natal depression.


2 Transcript, page 20

3 Transcript, page 21

4 Exhibit C9, page 41

3


She said that she herself would not be able to support Michaela’s attendance at Seymour College. She said that Michaela’s father was critical of Michaela in the way that she dressed, that he was only interested in Michaela’s academic performance and that nothing else counted. She said that the father made threats that Michaela might be withdrawn from the school and that he also did not support her wishes to attend drama classes. Michaela’s mother also informed Ms Hotich of her own family history of mental illness which included depression on the part of her mother which had required shock therapy.

3.3. In her session with Michaela, Ms Hotich said that Michaela described herself as feeling very depressed. When asked about suicidal ideation, Michaela said she had thoughts of death every day but that there was rarely any planning. Ms Hotich said

Michaela described a vague thought about possibly ‘OD'ing’ on ‘something’, but she went on to add that she would not do that because she did not want to hurt people and it would probably be a bad decision5.

3.4. Ms Hotich said that she completed an interim risk assessment6. This assessment was part of the initial consultation report and it was prepared on 8 July 2011. She assessed Michaela’s risk of suicide and self-harm as low. She said that because there were no explicit plans and the only thing that had been mentioned7 was rather vague, Ms Hotich regarded risk as low8. She added that overdose is a low lethality method of self-harm.

3.5. Notably, in the initial consultation report under the heading ‘Description and history of the problem’, Ms Hotich recorded the following:

'Mother describes a difficult relationship with Micky’s father, both during and after their separation. Father can offer a nice house, a good private school for Micky but is also verbally abusive, controlling and not aware or not caring all too much about Micky’s needs. Mother is more attuned to her daughter’s needs but says she could not offer her daughter the lifestyle she gets with Dad. She also could not financially afford to have both her older biological children live with her, but has offered that to Micky.'






5 Transcript, page 28

6 Exhibit C9, page 50

7 The reference to ‘OD'ing’

8 Transcript, page 31

4


Under the further heading ‘Clinical formulation’, Ms Hotich wrote:

'Depressive episode with anxiety, some self-harm and thoughts of death, likely because of ongoing unmet emotional needs plus verbal abuse and controlling/manipulative behaviours from father (mostly?).'

Under the further heading ‘Interim interventions’, she wrote:

'Explore family relationships with intent to find most supportive setup for Micky (physically and emotionally) and teach strategies to reduce depressive thoughts/feelings.'

It will be recalled that at this time Ms Hotich had spoken only to Michaela and her mother. She had not confirmed any of the allegations against the father. Although she did write the word ‘mostly?’ after recording in her clinical formulation that Michaela’s depressive episode was likely because of ongoing unmet emotional needs plus verbal abuse and controlling/manipulative behaviours from father, it is disturbing that she seems to have at a very early stage, made a judgment that the father probably had been guilty of these behaviours, thus causing Michaela’s depressive symptoms.

3.6. Ms Hotich saw Michaela for a second time on 22 July 2011. On this occasion she spent more time with Michaela and completed a risk assessment plan after the session. In this session she asked Michaela more about her self-harming. Michaela told her that she had cut herself because the pain from cutting was a different pain to take away the pain in her head. Following this second session Ms Hotich prepared a care plan9. The care plan recorded that the presenting concerns were a depressive episode with signs of anxiety, deliberate self-harm and ruminations about death. The risk of suicide was recorded by Ms Hotich as being low and the risk of self-harm was also described as low. The plan was to introduce strategies to reduce Michaela’s symptoms of depression and to manage her deliberate self-harm and suicidal thoughts. Ms Hotich recorded under her reasons for reaching the clinical judgment about risk assessment, the following:

'Deliberate self-harm and thoughts of death, but also a clear statement that she would

“never do that”. She seems not prone to highly impulsive behaviours. She is well connected socially and is just starting a relationship with a young man she has been friends with for a long time, so overall risk is considered low. However, because of depressive symptoms and deliberate self-harm, risk should be checked regularly.'






9 Exhibit C9, pages 13-14

5


3.7. In her session notes of this meeting, Ms Hotich recorded Michaela as having told her that her father was ‘really, really strict’ and that he yelled a lot. Her father expected her to be doing homework and chores all the time. She said that her father expected her to respect people but he did not do so himself. That he expected people to be caring but was not so himself and expected her to talk respectfully but he did not do that either. She said that she would appreciate more freedom to see her friends and not be pressured by her father about school performance and to do sport. She said she had tried to talk to her father about that and school counsellors had tried to speak to him also. She said that her father would not listen to her. She said that her father did not really know how depressed she was and was not aware of the cutting. She described her feelings while living with her mother as being much the same mentally and emotionally. She said that her mother’s household was much more laid back and in fact was sometimes too much so. She said it was totally different from her father’s and so it confused her, especially about pressure to study. She actually said that when it came to pressure and study she thought she was more like her father and added that it was good that he wanted her to do well, but that he went over the top.

3.8. Interestingly, Ms Hotich notes in this session that Michaela had talked to her mother about medication and had heard about antidepressants. Ms Hotich said that this revelation was probably a result of some questions that she asked Michaela about her knowledge of these things10. It was clear that Ms Hotich was not proposing medication for Michaela at that stage. Ms Hotich said that she gave no thought to the involvement of the CAMHS’ psychiatrist at that stage11 and that CAMHS’ guidelines were that psychological treatment would be tried as first line treatment for 3 months or 4-6 sessions before consideration will be given to the involvement of a psychiatrist12.

3.9. Ms Hotich said that the third attendance with Michaela was on 29 July 2011. She said that by this session she felt that she still had not established a therapeutic alliance to her satisfaction and that Michaela’s engagement was tentative and tenuous13. Ms Hotich was desirous of improving Michaela’s engagement with her. Michaela rated her depression over the period since the last session at 9.5 out of 10. She said that when she was with her boyfriend she felt better. Ms Hotich obtained Michaela’s

10 Transcript, page 35

11 Transcript, page 36

12 Transcript, page 36

13 Transcript, page 37

6


agreement to meet for a number of sessions to see how she responded to counselling. Ms Hotich had two intentions, the first one was to explore the family relationships and the second was to teach Michaela strategies to reduce her depressive thoughts by cognitive behaviour therapy. Michaela was to measure her rates of depressive symptoms on a scale between 0 and 10 with 10 being the most severe and 0 being the least14. Ms Hotich said that during that third session she did not question Michaela about the topic of suicidal ideation15.

3.10. The fourth session occurred on 2 September 2011. On this occasion Ms Hotich obtained from Michaela her ratings of her depressive symptoms. She recorded these as having been mostly 9 out of 10 or 9.5 out of 10 for ten days and only one day at 5 out of 10 when Michaela saw her boyfriend. On this occasion Ms Hotich recorded having interviewed both Michaela and her mother. She saw firstly Michaela’s mother. She informed Ms Hotich that Michaela had reported that a car had been stalking her. She reported that Michaela’s father had found out about Michaela’s boyfriend and had been yelling at her and bullying her. She said that Michaela was spied on during the weekend while staying with her (ie Michaela’s mother). Michaela’s mother went on to say that Michaela’s father had done the same thing to her (ie Michaela’s mother) in the past. Michaela said that she had not gotten the registration number of the car and that these events only happened on the weekend or when Michaela was alone. Michaela reportedly felt invaded by the experience but noted that the car that was following her was not her father’s car.

3.11. When Ms Hotich met with Michaela on this occasion, Michaela made reference to her father and the car16 saying that this had happened on two occasions. Michaela went on to say that she was really stressed out and had had a particularly bad week in which she had been arguing with her father and stepmother most of the time. She said that she had felt more depressed but had not gone back to cutting. She said that her father had threatened that if she did not do as he said, he would make her life hell or take her out of drama and out of Seymour College. He also forbade her to see her boyfriend unless he was aware. Michaela was concerned that her school grades were dropping very badly at the moment and said that she had had a migraine for the previous three days as a result of her stress. She had done her ratings and I have already made reference to those. Ms Hotich’s notes record that there was a discussion

14 Transcript, page 39

15 Transcript, page 38

16 Ms Hotich understood Michaela to have connected the car with her father – in other words, that Michaela believed her father was ‘stalking’ her

7


about Michaela’s living arrangement ‘options’. They were noted as, firstly, living with friends, secondly, living at Dad’s and, thirdly, living at Mum’s. The first option of living with friends was what not really practicable as she did not have money, it would make both parents angry and would involve a change of school. The option of living at her father’s was ‘worse’ and she noted that her father would not change and that she felt ‘paranoia’ and was really ‘freaked out’ and stressed. The possible arrangement of living with her mother would involve less stress but her mother did not really care about people or her environment and that living with her mother would involve a change of schools.

3.12. Finally, Ms Hotich noted that they discussed ‘emotional impact of controlling abusive father’ and noted ‘I suggested her depression likely is related to her living circumstances’17.

3.13. Ms Hotich said in her evidence that on this fourth occasion Michaela’s engagement was still not addressed to her satisfaction18.

3.14. During her session with Michaela’s mother on 2 September 2011, Ms Hotich made a note that the school counsellor will try to speak to Michaela’s father, but not mention the expression ‘depression’ because Michaela’s father ‘thinks that’s ‘b….sh..’19. This was followed by a note as follows:

'Rosie Lake (head of middle school) – Me talk to her Maybe too – Rebecca – school counsellor' 20

Later  in  her  evidence  Ms  Hotich  agreed  that  this  appeared  to  be  a  request  by

Michaela’s mother that she (Ms Hotich) would speak to Rosie Lake who was the

Head of the middle school at Seymour. Further, that she may also speak to Rebecca, the school counsellor there.

3.15. Ms Hotich’s fifth session with Michaela took place on 14 October 2011. An interim session had been cancelled21. At this session Michaela reported that her school camp had not been good. Ms Hotich said even on this fifth session the therapeutic engagement was only ‘tentative’ and that Michaela was not positively engaging with her22.



17 Exhibit C9

18 Transcript, page 38

19 This was explained in evidence as ‘bullshit’
20 Exhibit C9

21 This was a session scheduled for 16 September 2011 – cancelled because Michaela had returned from a school camp tired

22 Transcript, page 42

8


3.16. Ms Hotich said that Michaela did not attend the next scheduled appointment which was for 28 October 2011. She received a phone call from Michaela’s mother on 15

November 2011 saying that Michaela did not want to continue with her engagement with CAMHS. Ms Hotich closed the file officially on 17 November 201123.

3.17. On 5 September 2011, following the conversation with Michaela’s mother about making contact with Ms Lake from Seymour College, Ms Hotich did indeed telephone Ms Lake24. Ms Hotich’s note of the conversation is significant and I set it out below. I do not set it out verbatim, rather where abbreviations appear I have adopted my understanding of their meaning. I believe the following is a fair and accurate description of that note:

'Phone call – Rosie – middle school coordinator

Yes her and Rebecca support her (Micky) also homegroup teacher

Father concerned re school performance and adolescent friendship choices

She’s a very torn young lady

Impact: struggling to complete things, to focus

Father very interested in her academic performance and her general wellbeing

If he’s not included in discussion re how Micky is, he might explode in the end School hasn’t told him re marks yet

Thinks home neither with father or mother is really good Vina make sure Micky is safe when father has been told marks

Difficult to deal with Ingrid, too, because her anger is still in the forefront of her mind Explained my goals with her

Rosie wants to be outright that school should tell father re Micky’s mental health, but not call it ‘depression’

Already interactions with father

School wants Micky to understand: teens end up worse off when keeping secrets from a parent. Rosie means that re the practical things. If she’s dishonest with that it will be harder for dad to understand/accept her depression

Vina: the victim possibly being blamed for not being very believable ….

Rosie understood

Had to stop. Client waiting. Might continue another time.' 25

Ms Hotich in her evidence agreed that there was a slightly different emphasis in her approach and that of Ms Lake. She agreed that Ms Lake was expressing the view that this is not a good situation, that Michaela’s father does not have the whole picture. Michaela’s father was concerned about Michaela’s marks and her wellbeing, but

Michaela and her mother will not let the school tell the father about the mental health issues. Ms Hotich’s position was that she agreed that this was not a good situation,


23 Transcript, page 45

24 Transcript, page 49
25 Exhibit C9

9


but that it is necessary to be very careful about what might happen when Michaela’s

father finds out about the mental health issues26.

3.18. Again, Ms Hotich agreed that Ms Lake was saying that mother and daughter had expressly said that the school was not to tell the father, but that Ms Lake wanted Vina

Hotich’s assistance to get the mother and daughter to a position where they would permit the father to be told27. Ms Hotich agreed that the difference between she and Ms Lake was that Ms Hotich was expressing a reservation about the consequences for Michaela when her father found out about the situation28. Ms Hotich agreed that by the end of the conversation she and Ms Lake had reached a position where what Ms Lake was asking Ms Hotich to do was not exactly what Ms Hotich was prepared to do29. After the interruption Ms Hotich did not ring Ms Lake back.

3.19. On 16 December 2011 Ms Hotich had another telephone conversation with Rebecca Forrest from Seymour College. Ms Forrest informed Ms Hotich that the school had been mediating between the family and Michaela and that Michaela’s father had seen a folder of Michaela’s drawings which he thought were ‘very dark’. Michaela’s father was moving to Sydney and as a result Michaela was to move into the boarding house. Ms Forrest was conveying this information to Ms Hotich because Ms Forrest wanted Ms Hotich to make an appointment with a view to assisting Michaela to make the transition to the boarding house. Ms Hotich responded by informing Ms Forrest that the file had been closed and that there were certain requirements in order to reopen the file30. She said that the requirements were that someone, either the school or a parent, needed to refer Michaela back to CAMHS and then she would need to go again through the process of being assessed, assigned a priority rating and then would be seen, depending on the length of the waiting list31. Ms Hotich agreed following that conversation that she would speak with Michaela’s mother or, hopefully

Michaela herself, however this never occurred32. Ms Hotich agreed that it was apparent from Ms Forrest’s comments in her conversation of 16 December 2011 that

Ms Forrest had not previously been aware that CAMHS had ceased involvement with Michaela33.


26 Transcript, page 58

27 Transcript, page 59

28 Transcript, pages 59 and 60

29 Transcript, page 60

30 Transcript, page 67

31 Transcript, page 68

32 Transcript, page 68

33 Transcript, page 69

10


3.20. In cross-examination Ms Hotich was asked whether Michaela’s maternal history of depression might dispose her to that condition. Ms Hotich was reluctant to agree with that proposition and only allowed maternal history as a slight factor. Finally she agreed that it should influence her assessment of risk however34.

3.21. Ms Hotich was asked about an aspect of the form she completed at the first session, namely the initial consultation report. That report contains a box ‘interim interventions’ under which the following appears:

'Interim Interventions

(Feedback to Client/Carer/Others, notifications, investigations needed, referrals, information gaps)'

Ms Hotich was asked whether the reference in the quoted words to ‘referrals’ might be a reference to a specialist or something of that nature. Ms Hotich replied quite defensively as follows:

'That might be, look just to clarify, we are all at CAMHS, we are all considered specialists in child and youth mental health problems.' 35

This prompted me to ask Ms Hotich whether she considered that she was permitted by CAMHS to make a formal diagnosis of depression. She responded in the affirmative36. This occurred towards the end of the day’s evidence. The following morning, after Ms Hotich had been giving evidence for a short time, I was prompted to ask her whether, given her evidence about her authority to diagnose depression, she believed that she was authorised to diagnose other mental pathologies such as schizophrenia. This caused her to respond that overnight she had thought about it and now did not believe that she had authority to officially diagnose a major depressive disorder as a social worker. Accordingly, she qualified her evidence of the previous day37. It is interesting that this qualification was not proffered at the beginning of the following day’s evidence, but rather after questioning had gone on for some little time and a particular line of questioning had prompted me to make the enquiry about schizophrenia. It does not reflect well on Ms Hotich that she did not volunteer the qualification at the outset of the second day’s evidence.




34 Transcript, page 100

35 Transcript, page 101

36 Transcript, page 102

37 Transcript, pages 118 and 119

11


3.22. In cross-examination Ms Hotich said that at CAMHS the staff have multi-disciplinary meetings monthly. Those meetings include all of the staff as well as the child psychiatrist. She was asked if she ever spoke to the CAMHS psychiatrist about Michaela’s risk and acknowledged that she did not38.

3.23. Ms Hotich was asked whether, as early as the first visit with Michaela when Michaela herself rated her depression as 9 out of 10, referred to self-harm and suicidal thoughts and was assessed by Ms Hotich as being a teenager with moderate to severe depression, she should have had a discussion with a psychiatrist. Ms Hotich responded in the negative. She responded that at CAMHS staff get a fair number of young people presenting with those issues and added ‘it’s still sort of our daily work’39. She added ‘we have limited access to our psychiatrist’ and ‘I think it means we carry a bit more risk that we would otherwise on our own’40. She was ambivalent in her evidence about whether it was possible for her to pick up the telephone and speak to an on-call psychiatrist41. I had the impression that although it was a possibility, it was by no means a frequent occurrence.

3.24. Ms Hotich acknowledged that after the fourth visit when she was concerned about the lack of progress and was thinking that it might be necessary to escalate Michaela’s care, she made no note to that effect in the casenotes42. She attributed this to carrying fairly high caseloads and added ‘sometimes we just don’t write everything down that may be, would be useful to write down’43.

3.25. Ms Hotich was cross-examined on the subject of the disengagement from CAMHS following the phone call from Michaela’s mother on 15 November 2011. She was asked if that was not an opportunity to attempt to take control of the situation by offering further treatment, for example from the child psychiatrist. She said that she did not adopt that course because Michaela’s mother spoke of clear plans she had to take Michaela to another counsellor whom Ms Hotich thought was a private

psychologist in Stirling. Ms Hotich said she was very confident that continued therapeutic support would happen44. She was asked whether it was appropriate to leave it to a parent to continue to engage and responded that CAMHS is not a

38 Transcript, page s103 and 104

39 Transcript, page 104

40 Transcript, page 104

41 Transcript, page 105

42 Transcript, page 105

43 Transcript, page 106

44 Transcript, page 111

12


mandatory service and cannot command engagement45. Ms Hotich acknowledged that she did not explain to Michaela’s mother in the telephone conversation of 15

November 2011 that there were other treatment options available at CAMHS, including a psychiatrist46. She acknowledged that she could and should have asked to speak to Michaela to ensure that she herself was comfortable with the decision47. She said that she was influenced in this approach because of her workload and agreed that it was a matter of resources. She said:

'I probably had 10 more matters that also really were concerning and I was probably okay to let it go because there were many other things calling for my attention.' 48

3.26. Ms Hotich was cross-examined on the subject of Michaela’s claims that her father was stalking her. Ms Hotich was asked whether that might have been an irrational thought process. She responded by saying that she did not think Michaela was out of touch with reality and did not have any sense of psychosis or early stages of psychosis. It was put to her that the idea of Michaela’s father stalking Michaela was rather improbable bearing in mind that she spent most of her time staying with him, and that this was suggestive of the thought of stalking being somewhat irrational. She responded by saying that if it were irrational, it would be irrational behaviour on the part of Michaela’s father49. This demonstrates to me a reluctance to acknowledge the possibility that Michaela’s father was not stalking Michaela at all, and that in fact

Michaela was attributing this behaviour to him incorrectly which was, in my opinion, a distinct possibility. Indeed, Ms Hotich said that she felt supported in her thinking on this subject by the fact that Michaela’s mother had also referred to the supposed stalking. She acknowledged that Michaela’s mother did not claim to have actually witnessed the stalking and finally conceded that therefore Michaela’s mother’s report of the event was no more than a repetition of whatever Michaela was saying about the matter and added nothing50. Ms Hotich did acknowledge that had she thought that Michaela had been displaying psychotic features, she would have immediately referred her to a psychiatrist51.




45 Transcript, page 111

46 Transcript, page 139

47 Transcript, page 139

48 Transcript, page 140

49 Transcript, pages 115 and 116

50 Transcript, page 117

51 Transcript, page 118

13


3.27. It is notable that Ms Hotich’s own records of this session where stalking was raised contains a reference attributable to Michaela that she was feeling ‘paranoia’. It was again put to Ms Hotich that this may have been indicative of an incipient psychosis and she responded:

'You know, now that you’re asking me these questions I’m starting to rethink but it happened, until the moment you asked me that thought had not occurred to me, from the way she was presenting.' 52

3.28. Ms Hotich acknowledged that on the occasion of the fourth session, which it will be recalled was on 2 September 2011, she did not enquire about Michaela’s suicidality. She responded by saying that she had asked her about that matter ‘only six weeks before’53. Ms Hotich said that she had thought that if she and Michaela could talk through how Michaela’s living situation was affecting her, and whether there were possible choices she could make where she would feel less depressed, that might be helpful to her54.

3.29. I must say this seems to me to be a very impracticable approach with a young person of the age of 15 years who really has no control over her own living arrangements.

Ms Hotich, when asked about Michaela’s very depressed state on this occasion55, responded ‘you know we see a lot of young people who present with worse’56. I was left with the feeling that Ms Hotich either did not appreciate, or perhaps was not sufficiently careful about, the precariousness of Michaela’s situation. Ms Hotich did not agree that by this stage Michaela needed to see a psychiatrist57.

3.30. Ms Hotich, it is fair to say, did not think that antidepressant medication was desirable for people under the age of 1858. Ms Hotich agreed that it would have been appropriate at that stage to have commenced discussions with a psychiatrist about the appropriateness of antidepressants59. Ms Hotich was asked about the guidelines she had referred to under which four to six sessions of psychological treatment were to be undertaken before consideration would be given for a referral to a psychiatrist. In particular, she was asked whether there was any guideline about how intensive or

52 Transcript, page 130

53 Transcript, page 120

54 Transcript, page 121

55 Ms Hotich herself recorded that Michaela’s self rating of her depression was mostly 9 out of 10 to 9.5 out of 10 for ten days with an exclamation mark thereafter - Exhibit C9, page 32

56 Transcript, page 121

57 Transcript, page 122

58 Transcript, pages 122-124 and Exhibit C17, page 7

59 Transcript, page 126

14


frequent the therapy sessions should be. She was asked whether it made any difference whether the sessions took place over a very short period, for example, five or six appointments within a fortnight, or over a period of months. She said that intensity does not affect the policy60.

3.31. Finally, Ms Hotich acknowledged that she did not support the notion of contacting

Michaela’s father and letting him know what was happening at CAMHS61.

4. The involvement of Seymour College


4.1. I have already made a number of references to the staff of Seymour College and their discussions with Ms Hotich. Two staff members of Seymour College gave evidence at the Inquest. They were Ms Rosie Lake who was the Head of the middle school at Seymour College and Ms Rebecca Forrest who was a school counsellor. It was those two staff members who predominantly dealt with Michaela’s mental health problems and who were discussing those problems with Michaela’s father and mother. The evidence also demonstrates that other members of the staff of Seymour College were very much aware of the issue and had some involvement in it, but the principal participants in this aspect of Michaela’s life at Seymour College were Ms Lake and

Ms Forrest.


4.2. Exhibit C16 was a statement of Ms Forrest. It contains 33 annexures. For the most part, the annexures are email extracts evidencing email contact about Michaela.

Many of the emails are between Ms Forrest and Michaela’s father. Some of them are internal emails between staff of Seymour College. Some of them are between staff of

Seymour College and Michaela’s mother. There are also handwritten notes of meetings. Taken together with some other annexures to Exhibit C15, which was a statement of Ms Lake, they constitute an extensive documentary record of the school’s involvement in Michaela’s mental health problem. They clearly demonstrate an extensive and intensive effort on the part, particularly of Ms Forrest and also Ms Lake, but also of other staff members at Seymour College. They are an extensive and impressive record of the school’s efforts to provide pastoral care for Michaela.






60 Transcript, page 125

61 Transcript, page 132

15


4.3. Michaela’s father, Mr Mundy, appeared for himself at this Inquest. He also gave evidence. At one point in his evidence he was asked whether he had contacted Dr Garrood at the Stirling Medical Centre at any time after becoming aware of the fact that Michaela was seeing him. Mr Mundy responded by saying that he did not and he added:

'We were advised through Rebecca Forrest at Seymour just to keep it at arm's length. We were very concerned about any hostilities and the flow-on effect to Michaela, so discussion was open about that.' 62

I do not think that Mr Mundy intended to be critical of Seymour College when he made that reference. Nevertheless, the issue was explored further. At one point, I observed, subject to anything that Mr Mundy might want to put to me, that it was my tentative view that I was most impressed with the way in which the school had handled its management of Michaela and I described its conduct as being exemplary and going ‘above and beyond’ what might normally be expected. At no point did Mr Mundy take issue with that characterisation of the school’s performance. Indeed, at one point Mr Mundy, in framing a question to Ms Forrest, said:

'I have acknowledged in the Court that you have done a job way above what anyone would do and I commend you for that.' 63

4.4. Unfortunately, Mr Mundy having been granted leave to appear, and having given evidence, did not further participate in the Inquest after an adjournment of several months, despite the Court and the Court staff having made him aware of the adjourned hearing dates. I make no criticism of him for that; clearly it is a most distressing matter for a parent to have to participate in any way in an Inquest into the death of his or her child. Nevertheless, had Mr Mundy wished to further pursue his suggestion that the school had encouraged him to remain at arm’s length from any health practitioners involved in Michaela’s care, he had an opportunity to do so and did not take it. In fact, the evidence in my opinion is very clear. No doubt the school staff members involved were encouraging Mr Mundy to give Michaela some latitude and ‘breathing space’ in his dealings with her. However, the school most certainly did not attempt to discourage him from involvement with the health professionals.

4.5. The evidence very clearly shows that from an early stage, the school encouraged

Michaela and her mother to reveal to Mr Mundy Michaela’s attendance at CAMHS


62 Transcript, page 261

63 Transcript, page 340

16


for treatment. It was Michaela and her mother who were reluctant to inform him of that. Indeed, it was the staff of Seymour College that gave the greatest impetus in the efforts to reach a situation in which that information would be shared with Mr Mundy.

4.6. In particular, Ms Lake met with Michaela’s mother to talk to her about these concerns. The school was concerned about the approaching parent/teacher meetings and Ms Lake asked Michaela’s mother to advise Ms Hotich of this in her next meeting with Ms Hotich. The telephone call between Ms Hotich and Ms Lake on 5 September 2011 was to enable the school to ask CAMHS to help Michaela and her mother get to a position where they were happy for Michaela’s father to be informed.

In that conversation there appeared to be a difference of opinion between Ms Lake and Ms Hotich as to whether it was advisable to make Michaela’s father aware of the mental health issue64. It was Ms Lake’s expectation that Ms Hotich would speak to Michaela’s mother and Michaela about these matters. It is not entirely clear, but it is probable that Ms Hotich never did do this.

4.7. It is entirely clear that Mr Mundy never had any contact with CAMHS. It is also clear that he had no contact with any other of the health professionals with whom Michaela came into contact. In some of those instances he had the necessary information to enable him to make contact had he chosen to do so. He did not.

4.8. In any event, by 23 September 2011, after a good deal of prompting by Ms Lake and

Ms Forrest, Michaela’s mother had given permission to Seymour College to raise the issue of Michaela’s mental health with Michaela’s father. On 7 October 2011, at a meeting during the school holidays, between Ms Lake, Ms Forrest and Michaela’s father and stepmother, it fell to the staff of Seymour College to advise Mr Mundy of the mental health problems being faced by Michaela. The school was placed in an extremely difficult position. In fact, the school became a conduit between Mr Mundy and Michaela’s mother. I agree with counsel for Seymour College in his submission that this was an extremely onerous situation for the college staff and that it was handled with great professionalism and skill.








64 Transcript, pages 58-60

17


5. 2011-2012 School holidays and early 2012 school year


5.1. The 2011 school year ended with a plan for Michaela to become a boarder the following year. This was a compromise between Michaela’s father, mother and

Michaela herself. Her father was working interstate during the week and it was therefore convenient from his point of view that Michaela would board. Michaela herself was probably less enthusiastic. In any event it appeared to be the general consensus that boarding was a good solution and might be beneficial for Michaela. A considerable amount of email correspondence passed between Mr Mundy and Ms Forrest on this topic65. Once again, it demonstrates a significant effort and level of commitment from Ms Forrest to assisting in arriving at a solution to the family’s problems. It is apparent from an email from Ms Forrest to Mr Mundy dated 25 November 201166 that Michaela had a considerable amount of input into the decision to board. It demonstrates also that the issue was extensively traversed with Michaela by Ms Forrest. It demonstrates Ms Forrest’s clear efforts to communicate openly with Mr Mundy and Michaela’s mother in seeking to achieve an outcome that would be beneficial to both of Michaela’s parents and of course, Michaela herself.

5.2. These discussions culminated in a document entitled ‘parenting plan for year 2012’ which can be found in annexure RF15 to exhibit C16. It states that as a result of a change in circumstances, an amended plan is necessary for the health, care, welfare, education and development of Michaela and that Michaela will reside at Seymour College in the boarding house from Monday to Friday.

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