Finding into death of Yvonne Rose Vizard

Contributing factors

• Moderate-severe expressive and receptive dysphasia post-stroke
• Personality and mood changes post-stroke not monitored or assessed
• Absence of routine mood screening during rehabilitation using validated tools
• No psychological assessment despite patient expressing wishes to be dead
• Families not educated about depression risk in stroke survivors (33% general, 60% with aphasia)
• Families not informed of doubled suicide risk in first two years post-stroke
• No documented screening for mood disturbance in community rehabilitation program
• Lack of information sharing about extent of brain injury to family
• Lack of communication about personality changes between clinicians and family
• Discharge planning did not address mental health risks

Coroner's recommendations

1. That the Stroke Foundation clinical guidelines include specific and timely education for family and caregivers of stroke survivors recognising their risk for developing depression, particularly in the year post-recovery, and the increased risk of self-harm following stroke. Guidelines should note that one in three stroke survivors is at risk of developing depression and stroke may double the risk of suicide even without diagnosed depressive disorder.
2. Education should include how family and caregivers can monitor how the stroke survivor is adapting to post-stroke living, what behaviours are attributable to stroke effects, and red-flag indicators requiring referral. For stroke survivors with dysphasia, families and caregivers should be made aware of the 60% risk of developing depression and that prior history of depression combined with dysphasia represents two major risk factors for depression.