Finding into death of Ms FSZ

Contributing factors

• Incomplete assessment and documentation of NLU's mental health diagnosis at LRH
• Inadequate communication of family violence risk to community mental health services at discharge
• Failure to place NLU on alcohol withdrawal scale despite documented withdrawal symptoms
• Unclear exclusion of schizophrenia diagnosis without documented clinical rationale
• NLU discharged without antipsychotic medication despite reports of auditory hallucinations
• Inadequate discharge planning and failure to confirm receipt of referral with receiving service
• Failure to conduct comprehensive risk assessment regarding NLU's risk to others
• Police failure to serve varied FVIO on NLU prior to his discharge from hospital
• The Orange Door failed to conduct risk assessment for NLU's violence and did not offer comprehensive support to FSZ
• FSZ's housing insecurity and lack of safe accommodation options forced her back into contact with perpetrator
• Insufficient crisis family violence accommodation in Victoria

Coroner's recommendations

1. The Victorian Department of Health, through the Council of Australian Governments, encourage the Commonwealth Government to consider a Medicare item number for family violence counselling and therapeutic services distinct from a general practitioner mental health treatment plan, and in the longer-term to establish a Medicare item number or similar mechanism that will allow medical practitioners to record a family violence-related consultation or procedure to more accurately ascertain the public cost of family violence
2. The Department of Families, Fairness and Housing provide a roadmap to implementation of recommendation 35 of the Legal and Social Issues Committee Inquiry into Homelessness in Victoria
3. The Department of Families, Fairness and Housing provide Safe Steps with the funding requested for the Sanctuary accommodation model in their budget bid for 2025-26, noting that this aligns with the recommendations of the March 2021 Legal and Social Issues Committee Inquiry into Homelessness in Victoria
4. The Department of Families, Fairness and Housing consult with Safe Steps on further expansion of the Sanctuary model to provide a range of Sanctuary facilities across metropolitan and regional communities to give greater choice and access pathways to people experiencing domestic and family violence, and for provision of specialist Sanctuary facilities to accommodate people with complex needs such as mental health and misuse of substances
5. The Department of Families, Fairness and Housing scale up long term investment in supported accommodation projects like Sanctuary to replace the hotel model