Finding into death of Samantha Jane Fowler

Contributing factors

• Schizophrenia with poor insight and medication non-compliance
• Lack of confirmation of GP engagement after mental health service discharge
• Inadequate discharge planning and transitional care
• No written safety plan or case closure communication to GP or school
• Child Protection closure without explicit monitoring arrangements
• Absence of mental health literacy programs for children
• Psychotic episode triggered by unknown cause
• Ms Fowler never attended the Edwardes Street GP clinic despite referral
• No awareness by services that Ms Fowler had disengaged from all medical support
• Reliance on school to report concerns without clear mechanism

Coroner's recommendations

1. Department of Health, Mental Health, Drugs and Regions to review the scope of the FaPMI (Families where a Parent has a Mental Illness) strategy rollout across all public mental health services and regions in Victoria
2. Ensure access by public mental health service families to peer support programs such as CHAMPS and PATS, regardless of where they live in Victoria
3. Ensure access by families from other services (alcohol and drug services, family support services, child and youth services, community health, Child Protection, and schools) to programs for families where a parent has a mental illness or significant mental health issue
4. Improve mental health literacy programs for children, teenagers and young adults of parents with severe mental illness