Finding into death of Sherry Ann Robinson

Contributing factors

• failure to identify the incident as a family violence matter despite existing intervention order
• incomplete information sharing between Victoria Police and hospital staff about threats made by patient
• loss of nursing assessment notes due to CMI system error
• mental health assessment conducted without access to patient's medical record or prior notes
• failure to obtain collateral history from family members
• incorrect contact details for patient's mother on file
• patient not disclosing current psychiatric treatment and medication
• assessment of low aggression risk despite recent threats
• failure to notify Victoria Police of patient discharge
• deceased not informed of threats or increased risk to her safety
• deceased unaware of perpetrator's acute mental health crisis

Coroner's recommendations

1. Chief Commissioner of Police should amend the Code of Practice for the Investigation of Family Violence to provide more specific guidance about how family violence incidents may present to police, including that: incidents may not be reported as family violence; family violence incidents need not be exclusively characterised as such; matters may be dual-categorised as both mental health and family violence issues; police should obtain additional information including LEAP checks where family violence risk factors are evident; and affected family members need not be present for an incident to constitute family violence (e.g., threats to absent family members)
2. Department of Health and Human Services and Chief Commissioner of Police should address in their shared Protocol for Mental Health the circumstances in which Victoria Police should be notified of discharge of a person apprehended under the Mental Health Act 2014, with consideration given to making such notification mandatory rather than contingent on risk assessment