Inquest into the death of Sabrina Di Lembo

19y · Female·self-inflicted hanging

Sabrina Di Lembo, a 19-year-old law student, died by suicide after experiencing anxiety and panic attacks during exam preparation. Over nine weeks, she had 17 medical contacts but received inadequate assessment, no detailed history-taking, and no formal diagnostic tools. Dr B. prescribed sub-therapeutic Efexor 37.5mg (minimum recommended dose 75mg), leading to deterioration attributed to the medication. When Sabrina stopped the drug, neither GP escalated to psychiatry or the Mental Health Service despite their involvement. The Mental Health Service referred her to a GP without face-to-face assessment, then closed her file without coordination with other providers. Key failures included: no specialist referral despite clear indication, poor note-taking, lack of care coordination, and failure to recognize that sub-therapeutic dosing prevented therapeutic benefit. The coroner found multiple missed opportunities where proper assessment and escalation could have altered the outcome.