Deceased
Katica Perinovic
Demographics
42y, female
Date of death
2021-01-14
Finding date
2022-11-15
Cause of death
Multiple stab wounds
AI-generated summary
A 42-year-old woman with first episode psychosis was referred to community mental health services in November 2020 after acute onset of paranoid delusions. She was commenced on risperidone but showed poor engagement and medication compliance. Between December 2020 and January 2021, clinical review was predominantly conducted via brief phone calls without documented mental state examinations, risk assessments, or psychoeducation. Collateral information from family was not systematically obtained. The patient took a risperidone overdose in December which was not communicated to her mental health team. She became non-compliant with medication in January 2021. On 14 January 2021, she fatally stabbed herself and her three children. The coroner found suboptimal mental health treatment with missed opportunities for intervention, including inadequate frequency and quality of reviews, failure to provide psychoeducation, lack of family engagement, poor medication monitoring, and insufficient communication with her GP.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
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Source and disclaimer
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