Finding into death of Jessica Morgana Wilby

Contributing factors

• Work-related major depressive disorder precipitated by role overload and toxic workplace culture
• Failure to adequately support employee after acute distress incident on 15 March 2018
• Lack of ongoing support from Court and CSV during three-month sick leave
• Workplace environment described as toxic with poor management, high staff turnover, and lack of clear roles
• Obsessional thoughts about workplace failure and reputational damage not specifically targeted in treatment
• Non-disclosure of serious suicide attempt to medical professionals
• Fear that hospitalization or disclosure of mental illness would damage career aspirations
• Multiple uncoordinated healthcare providers with inconsistent follow-up
• Perfectionistic personality traits and tendency to ruminate
• Polypharmacy leading to serotonin syndrome

Coroner's recommendations

1. Implementation of Health and Wellbeing Plan by the Court, already substantially completed by the date of finding
2. Structural changes to Legal Services to enhance supervision and strengthen line management
3. Creation of roles including Director People and Wellbeing and Health and Wellbeing Advisor
4. Programs on mental health, vicarious trauma, peer support, supervisory training emphasizing occupational health and safety obligations, and refreshed induction programs
5. Employee access to four sessions annually with external psychologist for vicarious trauma
6. Operational Risk Registers and health and wellbeing intranet resources
7. Development of new strategic plan and values statement to guide conduct, behaviour and culture
8. Coordination between Court Services Victoria and the Coroners Court to ensure adequate workplace support systems