Inquest into the Death of Tedeschi
Deceased
Gabrielle Mia Tedeschi
Demographics
14y, female
Date of death
2004-10-14
Finding date
2007-12-03
Cause of death
Ligature compression of the neck (suicide)
AI-generated summary
Gabrielle Mia Tedeschi, a 14-year-old girl with longstanding oppositional and self-harm behaviours and subsequent depression, died by suicide on 14 October 2004 following a ligature compression injury sustained on 11 October 2004 at home. She had been treated with multiple anti-depressant medications (fluoxetine then venlafaxine) prescribed off-label by her psychiatrist, Dr S.. Key issues identified: inadequate communication between public hospital (Princess Margaret Hospital) and private treating clinicians; Gabrielle ceased venlafaxine around 7 October 2004 without medical supervision; insufficient face-to-face monitoring by her psychiatrist after commencing venlafaxine; and failure to provide Consumer Medicine Information (CMI) sheets detailing withdrawal risks and suicidality warnings. The coroner found her behaviour on 11 October was likely related to cessation of venlafaxine and re-emergence of her illness, though the impulsive nature of her suicide means early intervention could have prevented it. Recommendations focused on clinician obligations regarding informed consent for off-label medications, regular clinical review, and ensuring pharmacies dispense updated CMI documents with appropriate warning labels.
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Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- cessation of venlafaxine medication without medical supervision
- re-emergence of depressive illness and suicidal ideation
- impulsive response to family conflict
- adolescent resistance to treatment and medication non-compliance
- inadequate frequency of psychiatrist review after commencing venlafaxine
- insufficient information provided to parents regarding withdrawal risks and suicidality warnings
- lack of communication between public hospital and private treating clinicians
Coroner's recommendations
- Clinicians prescribing SSRI and SSNRI type anti-depressant drugs should be scrupulous to ensure those taking the drugs, or their parents or guardians, are fully informed of all pertinent facts about the drug before prescribing it to patients. This could be emphasised by Clinicians providing up to date CMI's as written back up.
- Clinicians prescribing SSRI and SSNRI type anti-depressant drugs should be scrupulous to ensure they physically review patients on a regular basis after prescribing the drug or upon any dosage change.
- There be appropriate amendment to pharmacy registration/licensing procedures to ensure up to date CMI's be provided with dispensed medication and appropriate warning labels (including warning label 9) be affixed to the outside of boxes containing SSRI and SSNRI anti-depressant medication.
Full text
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