Inquest into the death of D T

Contributing factors

• Inadequate general practitioner assessment of mental health
• Lack of proper mental health screening before antidepressant prescription
• No follow-up or monitoring of antidepressant therapy
• Failure to refer to mental health specialist despite clear indicators
• General practitioner's lack of empathy and insufficient care
• Mother's incapacity due to pain medication and health conditions
• Educational neglect and chronic school refusal
• Family isolation and lack of external support
• Multiple unaddressed reports to child protection authority
• Screening out of child protection reports at Helpline stage
• Child protection system unable to respond due to resource constraints

Coroner's recommendations

1. The Department of Family and Community Services give urgent consideration to amending existing policy/procedure so that where a mandatory report is made and screened out as non-ROSH, the mandatory reporter is advised of the outcome within 21 days
2. Introducing and evaluating further training for Helpline and CSC staff in respect of unconscious bias when dealing with parents who have separated from the primary carer and are reporting concerns about their children
3. Creating a referral service operating at the Helpline stage, so that where referrals are screened out as non-ROSH, reporters are informed that the information will be kept on file as relevant history in the event of further calls and the referrer is given the contact details of other service providers that may be able to assist (e.g. Anglicare, CatholicCare, local adolescent medical health services, Brighter Futures)