Catherine Lynch, a 41-year-old nurse, died from mixed drug toxicity in July 2022 in circumstances consistent with suicide. She was experiencing severe family violence, including coercive control, threats, stalking and emotional abuse from her partner Mr TT over several years. Her treating clinicians—psychiatrist, two psychologists, GP, and day therapy program—were aware of various indicators of family violence but did not explicitly identify, assess or respond to it. No referrals to specialist family violence services were made. The coroner found that while clinical care was generally competent, responses to family violence disclosures could have been improved. Key clinical lessons include: private mental health professionals lack mandatory family violence training and are not prescribed under MARAM; mental health clinicians must regard family violence identification as part of their responsibility; family violence is a known risk factor for suicide; and consistent messaging and support about family violence across all treating clinicians may have altered Catherine's experience. The coroner emphasised that family violence education must be embedded in training pathways for all mental health professionals.
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Family violence perpetrated by partner including coercive control, threats, stalking and emotional abuse
Failure of mental health clinicians to identify, assess or respond to disclosures of family violence
No referrals to specialist family violence services despite multiple indicators
Lack of mandatory family violence training for private mental health professionals
Private mental health professionals not prescribed under MARAM framework
Deterioration in mental health in period prior to death
Breach of FVIO by partner and continued abuse despite protective orders
Partner's encouragement to patient to take own life as documented in diary
Coroner's recommendations
The Royal Australian and New Zealand College of Psychiatrists introduce mandatory family violence training into their fellowship training for new psychiatrists
The Psychology Board of Australia explicitly recognise in the Professional Competencies for Psychologists that competency in family violence risk assessment and management is relevant to all practice settings and explicitly outline an expectation that all psychologists are competent in family violence identification, assessment and management
The Psychology Board of Australia consider this finding and include mandatory education on family violence identification, assessment and management in their recommendations to the Department of Health, Disability and Ageing on the redesign of the psychology higher education pathway
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