Finding into death of Daniella Francesca Sessarego

Contributing factors

• Access to pentobarbitone at veterinary workplace
• Inadequate storage security of pentobarbitone in veterinary clinic
• Recent job loss
• Recent relationship breakdown
• Increased suicidal ideation and hopelessness
• Borderline personality disorder with chronic self-harm risk
• Major depressive disorder

Coroner's recommendations

1. That the Veterinary Practitioners Registration Board of Victoria extend its guideline for enhanced record keeping and labelling/dispensing of Schedule 8 drugs to pentobarbitone, requiring all pentobarbitone transactions to be recorded in a separate record book (not in patient medical records) with details of date, quantity, veterinary practitioner name and signature, and true balance recorded following each transaction
2. That the Veterinary Practitioners Registration Board of Victoria recommend to its members that pentobarbitone is stored in a drug safe accessible only by a veterinary practitioner or by staff under a veterinary practitioner's direction, that is date and patient-specific and includes a direction to account for or dispose of unused portions