Finding into death of Caitlin Mary O'Brien

Contributing factors

• Failure to complete adequate family violence risk assessment by Alfred Health mental health clinicians
• Failure to develop safety plans for Ms O'Brien despite documented family violence
• Inadequate exploration of family violence risk during psychiatric assessment on 23 June 2019
• Psychiatric assessment reflected perpetrator's victim-blaming narrative rather than documented risk patterns
• Discharge of Mr Sturt the same night despite known family violence history and acute mental health crisis
• Failure by Victoria Police to identify and report family violence during mental health transfers
• Police did not make proactive enquiries about family violence despite known history at same address
• Inadequate communication from Alfred Health to police and paramedics regarding family violence risks
• Lack of family violence specific training and systemic processes in mental health services at time of incident
• Limited follow-up by Alfred Health after Ms O'Brien declined family violence support services
• No application for Family Violence Safety Notice despite documented threats to kill

Coroner's recommendations

1. Alfred Health and other mental health services should ensure all clinicians receive mandatory training in family violence risk assessment aligned with the MARAM Framework
2. Mental health services should establish streamlined access to family violence expertise for high-pressure environments where key risks or red flags are present
3. When a patient with known family violence history presents for mental health assessment, clinicians should conduct formal family violence risk assessments and work with affected parties on safety planning
4. Mental health clinicians should be alert to victim-blaming narratives presented by perpetrators and ensure prior documented patterns of violence are reflected in assessments and discharge planning
5. Victoria Police should conduct LEAP checks on premises and persons involved before attending mental health incidents to determine if there is a history of family violence
6. Victoria Police should make proactive enquiries about family violence risk even where family violence was not the initiating report, particularly in mental health incidents
7. Police should provide relevant information about safety risks including family violence to examining mental health practitioners regardless of whether examination is in community or hospital
8. Police should make appropriate referrals for all parties involved in family violence incidents through the Family Violence Portal in line with the Mental Health Protocol
9. Mental health clinicians should ensure that discharge planning includes communication to police or other agencies where family violence risks are identified
10. Health services should follow up with patients who decline family violence support services to further explore risks and explore barriers to engagement