Inquest into the Death of Tedeschi

14y · Female·Ligature compression of the neck (suicide)

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.