Inquest into the death of Sabrina Di Lembo

Contributing factors

• inadequate mental health assessment by both General Practitioners and Mental Health Service
• failure to take detailed history
• prescription of sub-therapeutic dose of venlafaxine (37.5mg vs minimum 75mg)
• failure to use formal assessment tools (K10, DASS, GAD7)
• lack of specialist psychiatric referral
• poor coordination of care between multiple providers
• Mental Health Service referral to GP without face-to-face assessment
• closure of Mental Health Service file without consultation with other providers
• patient deterioration attributed to medication rather than suboptimal dosing
• failure to escalate when patient stopped antidepressant and experienced suicidal ideation
• inadequate note-taking preventing care continuity
• lack of communication between psychiatrist and family despite repeated contact attempts
• General Practitioners not consulting Mental Health Service when recommending medication cessation

Coroner's recommendations

1. Top End Mental Health Service must ensure all clients are properly assessed before deciding to refer care to General Practitioners
2. The role of Top End Mental Health Service in care and treatment must be explicitly stated to client and family
3. Top End Mental Health Service must have specific procedure for proper coordination with all relevant providers when retaining any responsibility
4. Before ceasing involvement, Top End Mental Health Service must contact all other relevant providers and obtain copies of their last consultations
5. Medical Board must remind General Practitioners of care and attention required and obligation to take detailed history, undertake appropriate assessment, and take proper notes when dealing with mental health presentations