Inquest into the death of Tahlia Peden

Contributing factors

• breakdown in referral pathway between Sexual Assault Services
• misinterpretation of JRU referral timeframes as non-urgent
• failure of Goulburn SAS to contact client
• different referral processes between Wagga and Goulburn SAS
• worker unavailable on critical day due to training
• inadequate handover documentation
• assumption by Goulburn that written referral would follow
• lack of Aboriginal Health Worker support
• previous trauma and mental health history not adequately escalated
• suicidal ideation underestimated in context of chronic history

Coroner's recommendations

1. That the Southern NSW Local Health District and Murrumbidgee Local Health District raise for discussion at the VAN Senior Executives Advisory Group Meeting procedures for SAS client referral from district to district and for that purpose, a copy of these findings be provided to attendees to facilitate discussion.
2. That a copy of the coronial findings be provided to the NSW Health Team at the Joint Investigation Response Team (JIRT) Referral Unit (JRU) to consider clarification around reference to time frames in JRU documents that are referred to a NSW Health Service.
3. That a copy of the coronial findings be provided to any committee overseeing the introduction of the Central Intake System and the audit of the use of the suicide risk assessment tool within the Southern NSW Local Health District with a view to ensuring that the proposed changes do not lead to any increased delay in client's accessing SAS or mental health services within the District.