Finding into death of Claire Perinovic
Deceased
Claire Perinovic
Demographics
7y, female
Date of death
2021-01-14
Finding date
2022-11-15
Cause of death
Multiple stab wounds to the back
AI-generated summary
Claire Perinovic, aged 7, died from multiple stab wounds inflicted by her mother Katica during a filicide-suicide incident. Katica had been diagnosed with First Episode Psychosis in November 2020 and treated by NorthWestern Mental Health (NWMH). The coroner identified significant deficiencies in her mental health care: inadequate frequency and quality of clinical reviews, limited face-to-face contact after December 2020, lack of formal mental state and risk assessments, absent psychoeducation, poor medication compliance monitoring, failure to detect a risperidone overdose, and inadequate family involvement. The coroner found treatment suboptimal but not causally linked to the deaths. Missed opportunities for intervention were identified, including failure to maintain contact with the GP and family, and inadequate escalation despite documented concerns about avoidance and symptom masking. NWMH has since implemented substantial reforms.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Mother's First Episode Psychosis
- Mother's non-compliance with risperidone
- Suboptimal mental health treatment by NWMH
- Inadequate frequency and quality of clinical reviews
- Lack of face-to-face assessments
- Absence of formal mental state and risk assessments
- Lack of psychoeducation
- Poor medication compliance monitoring
- Failure to detect mother's risperidone overdose
- Inadequate family involvement in treatment
- Poor communication between NWMH and GP
- Missed psychiatrist appointments not adequately addressed
Coroner's recommendations
- The Royal Australian and New Zealand College of Psychiatrists should review and update the Clinical Practice Guidelines for the Management of Schizophrenia and Related Disorders to improve best practice in clinical care provided to patients diagnosed with First Episode Psychosis in community mental health practices
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