Coroner's Finding: DOBRIJEVIC Sofija

73y · Female·neck compression by ligature

Sofija Dobrijevic, a 73-year-old woman detained under the Mental Health Act, died by ligature strangulation in a closed psychiatric ward at Glenside Hospital. She had chronic pain since a 2002 fall, depression, and histrionic personality disorder. Two days before her death, she told her son she would be 'found dead tomorrow' and he would 'be planning her funeral,' but this critical information was not effectively communicated to treating psychiatrists due to communication breakdown between her son, a junior medical officer unfamiliar with psychiatry, and the psychiatric registrar. The clinical team assessed her as moderate risk of self-harm without access to this information. Despite her longstanding suicidal ideation history, risk assessment protocols focused on acute vocalised intent rather than her longitudinal mental health history. Had the family's concerns been properly escalated to the psychiatrist, intensive observation and high-risk management strategies would likely have prevented her death.