Inquest into the death of Sabrina Josephine Di Lembo
[2018] NTLC 28
•3 December 2018
CITATION: Inquest into the death of Sabrina Josephine Di Lembo
[2018] NTLC 028
TITLE OF COURT: Coroners Court JURISDICTION: Darwin FILE NO(s): D0136/2017 DELIVERED ON: 3 December 2018 DELIVERED AT: Darwin HEARING DATE(s): 23 – 25 October 2018 FINDING OF: Judge Greg Cavanagh CATCHWORDS: Anxiety, young woman, suicide, NT
Mental Health Service, General
Practitioners, no adequate history or
assessment, no coordinated care, no
referral by GP to psychiatristREPRESENTATION: Counsel Assisting: Kelvin Currie Counsel for Top End Health Service: Stephanie Williams Counsel for Dr Britz: Peter Mariotto Counsel for Dr Chapman: Miles Crawley SC Counsel for the Di Lembo family: Matthew Littlejohn Judgment category classification: B
Judgement ID number: [2018] NTLC 028 Number of paragraphs: 114 Number of pages: 34
IN THE CORONERS COURT
AT DARWIN IN THE NORTHERN
TERRITORY OF AUSTRALIA
No. 136/2017
In the matter of an Inquest into the death of
SABRINA JOSEPHINE DI LEMBO
ON 7 AUGUST 2017
AT PARAP
FINDINGS
Judge Greg Cavanagh
Introduction
Sabrina Josephine Di Lembo was born in Darwin on 5 May 1998 to
Michael and Lidia Di Lembo. She had two older brothers, Joshua and
Anthony.
Her history was provided during the course of the inquest by her family in
these terms:
“Sabrina was our third child, after having two sons, Anthony and
Joshua. Sabrina was cherished, loved and adored by all her family, immediate and extended. She had a happy and normal childhood. Although not outgoing, she was looked up to by her friends and elected captain of her sports team in primary school, even though she
wasn’t the sporty type, and she received the Thomas Lubi Award
which is only give to one student at St Paul’s Primary in her final
year.
She led a normal young life playing basketball, learning the piano and did calisthenics. She eventually grew to enjoy the gym and walking with us or her friends. After completing year 12 at Darwin High in 2015, Sabrina enrolled in a Bachelor of Laws at Charles Darwin University and was awarded the pro vice chancellor scholarship granted to only two students. Sabrina was ecstatic and we were all so proud of her achievements.
Sabrina not only wanted to do well throughout her years in school and university, she was a dedicated student and pushed herself to excel. In fact, her brothers would often tell Sabrina to not study so
hard and that if she got a pass for a subject it was okay, speaking
from their own experience.Sabrina also worked as a casual employee at a number of businesses with her last job being with BreastScreen NT where she was highly regarded and respected by her work colleagues.
Sabrina was a serious but witty young woman who got on well with everyone. Her close friends who are absolutely devastated at losing their confidante and mother hen, they spent several holidays together
and often caught up for coffee and lunch. Sabrina was very caring, affectionate, loyal, grounded and dedicated to whatever she put her mind to. She had so much going for her and had planned her life to work as a lawyer. She certainly knew how to mount a good argument
having had a lot of experience sparring at home with her brothers and
us.”
In her second year of university (2017), toward the end of the first
semester, she had an assignment and two exams approaching. The exams
were on 6 and 9 June and the assignment was due on 12 June 2017.
During May she studied hard, often into the early hours of the morning.
In the last week of May 2017 she became anxious. She couldn’t sleep. She
started having panic attacks three or four times a day. Her mother was
away at the time. Sabrina rang her frequently for advice and support and
it was arranged that her father would take her to see a General
Practitioner (GP).
She saw a GP on 30 May 2017. She told the GP that she couldn’t
physically cope anymore. The GP gave her a medical certificate to assist
in deferring her exams. The certificate stated: “She cu rrently does not
have the physical or mental capacity to complete these assessments at this
time”. The GP also provided her Restavit to help her sleep.
Mrs Di Lembo returned shortly thereafter and found that her daughter was
still very anxious. Sabrina wanted to talk about her issues constantly,
even through the night. Her mother was so concerned she slept in
Sabrina’s room.
Sabrina saw the same GP again on 2 June 2017 in the company of her
mother. Sabrina told the GP that her exams had been deferred, that she
was sleeping and that her panic attacks had ceased. The GP provided a
medical certificate to facilitate her mother taking carer’s leave to help
Sabrina cope.
However, Sabrina continued to be extremely anxious and five days later,
on 7 June 2017, her mother contacted the Access Team of Top End Mental
Health Service (Mental Health Service) by telephone. She said that
Sabrina had already been to a GP on two occasions in the last week. She
said Sabrina was having difficulty focusing and seemed completely
overwhelmed. She said she was “spiralling”. She said Sabrina couldn’t
control her thoughts and felt she couldn’t continue anymore.
The mental health clinician also spoke to Sabrina during that telephone
call. Sabrina said she was due to commence a work placement in a week
and a half and was panicking about it. Sabrina’s biggest fear was that she
would not be “normal”, that she wouldn’t be “switched on”. When asked,
Sabrina denied having thoughts of self-harm.
The mental health clinician asked for Sabrina’s email address and sent to
her information to do with anxiety, depression and suicide. The clinician
said Sabrina’s issues were not acute and could be managed by a GP. The
clinician suggested that Sabrina be taken to see Dr Britz at the Tristar
Medical Centre in Parap.
Less than two hours later at 12.26pm Sabrina and her parents attended on
Dr Britz. The medical notes relating to that visit were as follows:
Visit Type:
Surgery Consultation
Reason for contact:
Anxiety
new onset anxiety
struggling with uni
struggling with everything
not suicidal
appointment with easa next weekdeferred assignments
Management:
trial of efexor
trial of low dose valium
long discussion on managementreview on tuesday
Actions:
Prescriptions added: EFEXOR-XR SR CAPSULE 37.5mg 1 daily
Prescription added: VALIUM TABLET 2mg 1 b.d.
Medicare Item:
441
Dr Britz indicated in evidence that on that day Sabrina was acutely
unwell. She thought looking back that she should have referred her to a
psychiatrist and that if she had known about the previous two
consultations with another GP in the last week she would most certainly
have done so.
Dr Britz told Sabrina that it would take some weeks before she
experienced the full benefit of the anti-depressant (Efexor).[2] The
following day Sabrina was taken by her mother to see a psychologist atEASA (a counselling service). There followed another five sessions.
On 13 June 2017 at 9.07am Sabrina and her mother saw Dr Britz once
more. The notes of that consultation are in the following terms:
Visit Type:
Surgery Consultation
Reason for contact:
Review
presents for review
better than last week
feels that the Valium makes her spacyadvised to take just as needed
planning better
still looking for uni options
not sure about workwill think about this more this week
history of heavy cycles
has had bloods and such done
not on contraception to help manage thesewould like a certificate for her mother to be off with her this week
Management:
certificate done
continue current medication
valium prn only
referred for ussreview with results on friday
Actions:
Diagnostic Imaging requested: US – Pelvis (F)
Letter Created – re. Certificate – parental leave to .Letter Printed – re. Certificate – parental leave to .
Medicare Item:
36[3]
Of prescribing the anti-depressant Efexor Doctor Britz said: “She didn't
appear resistant to trialling medication. I think she was quite keen to stop
the symptoms that she was suffering”.4
Three days later on 16 June 2017 Sabrina and her mother saw Doctor
Britz again. The notes of the consultation are in the following terms:
Visit Type
Surgery Consultation
notes completed from visit today
really not sure how things are goingdistressed more because she is unsure about what is going on
supposed to be doing a work program over the semester break
associated with a scholarship
not sure if she is fit to start this
in 2 minds whether she will go to the orientation next week or nother mother has been off with her needs medical certificate for this mother unsure if they should go away or look at a retreat or
something
pt in 2 minds about this as well
Management
certificate given
certificate for mother given
Item 36: Professional attendance by a general practitioner at consulting rooms
(other than a service to which another item in the table applies), lasting at least
20 minutes and including any of the following that are clinically relevant:
a) taking a detailed patient history; b) performing a clinical examination;
c) arranging any necessary investigation;
d) implementing a management plan;e) providing appropriate preventive health care;
for one or more health-related issues, with appropriate documentation-each
attendance.
4 Transcript p 15
given another script of low dose efexor as I will be away
discussed services available whilst I am away
discussed general managementto continue with psychologist
Actions
Letter Created – re. Certificate – Time off medical reasons to .
Letter Printed - re. Certificate – Time off medical reasons to .Letter Created – re. amended medical certificate to .
Letter Printed - re. amended medical certificate to .
Prescriptions printed:
EFEXOR–XR SR CAPSULE 37.5mg 1 daily
Medical Item:
44
At that point in time Dr Britz had seen Sabrina on three occasions in the
space of 10 days. Sabrina was not improving. Dr Britz had not taken a
detailed history, she had not taken adequate notes of her consultations and
she had not administered any assessment tools (such as the K10 or
DASS). The diagnosis and the severity of Sabrina’s symptoms remained
unknown.
The compounding feature was that the minimum recommended dose of
Efexor is 75 milligrams. That is plainly stated on the information that
accompanies the medication. As such, the therapeutic effect (making her
more relaxed and less anxious)[5] for which Sabrina and her family were
waiting was unlikely to eventuate while on 37.5mg.
On 19 June 2017 a mental health clinician from the Mental Health Service
contacted Mrs Di Lembo. The clinician was told that Dr Britz had
commenced Sabrina on Efexor 37.5mg and low dose Valium. Mrs Di
Lembo said a friend, who was also a psychiatrist, had suggested to her
that the anti-depressant Escitalopram and cognitive behaviour therapy
may be better. The mental health clinician told Mrs Di Lembo she would
need to talk to the GP or see a private psychiatrist. The clinician thenspoke to Sabrina. She sounded tired. Her delivery was “monotonous, flat”.
She said she had lost interest in normal past-times and couldn’t be
bothered taking care of herself.
The following day her case was discussed by the Top End Mental Health
morning clinical review multi-disciplinary team. It was noted that Sabrina
had been commenced on Efexor 37.5mg.
On Sunday, 25 June 2017 a mental health clinician from Mental Health
Service called and spoke to Mrs Di Lembo again. Mrs Di Lembo
confirmed that Sabrina was not improving. She said Sabrina was losing
hope of improving. Mrs Di Lembo asked when there would be a change.
The clinician told her that the medication needed time to take effect.
Mrs Di Lembo asked about the possibility of trying a different
medication. She was told that she was better off discussing that with Dr
Britz. The clinician said that if Dr Britz needed to discuss that with the
psychiatrist she could do so. Mrs Di Lembo said she wanted feedback
from the psychiatrist.
The clinician passed that request on by email to Dr David Chapman, the
psychiatrist in charge of the Access Team. Dr Chapman replied in the
following terms:
“What dose is she on currently? If 37.5mg then increase immediately
to 75mg and stay on that for 1 week then increase to 112.5mg until
review by Dr Britz. Tell mum to stop trying to be a doctor.If she is having trouble sleeping then mirtazapine 7.5mg nocte as required.
No one seems to have asked about family history.”
Mrs Di Lembo was trying her best to find a way to engage with the
medical profession to relieve her daughter of the suffering she was
experiencing. At that point in time she was attempting to resolve the
continuing deterioration of her daughter’s health with the information that
she may do better with different medication and therapy. In my view the
suggestion by Dr Chapman, that Mrs Di Lembo be told to “stop trying to
be a doctor”, at best, showed a significant lack of empathy.
The mental health clinician called Mrs Di Lembo to tell her of Dr
Chapman’s recommendations. However she was not told that 37.5mg was
a sub-therapeutic dose. It was not explained that increasing it to 75mg
was simply raising the dose to the minimum recommended level. Mrs Di
Lembo said she was hesitant about the increase and did not think Sabrina
would be happy to increase the medication.
Four days later on 30 June 2017 Mrs Di Lembo called the Mental Health
Service. She said they were concerned that Sabrina was being over-
medicated. It is likely that Sabrina and her parents attributed her
deteriorating condition to the medication. Mrs Di Lembo asked to talk to
Dr Chapman. He refused to talk to her, saying he could not do so because
Sabrina was an adult. He said she should speak to a GP.
That afternoon (30 June), Sabrina and both her parents went to the Tristar
Medical Group at which Dr Britz practiced. Dr Britz was on holidays.
They saw Dr Bernard Westley, the senior doctor and Medical Director of
the Tristar practice in the Top End. Into the medical notes Dr Westley
copied an email from the Top End Health Service that had been received
the day before. It relevantly stated:
“Sabrina is a Law Student and resides with her family and has
developed depressive and anxious symptoms that are quite disruptive
and ruminative thinking and middle insomnia, tiredness, lethargy,low mood and poor concentration.
Dr Chapman makes the following suggestion for her treatment
planning: “if only on Efexor 37.5mg then increase immediately to
75mg and stay on that for 1 week then increase to 112.5 until review by Dr Britz. If she is having trouble sleeping then mirtazapine 7.5mg
nocte as required.”
The medical notes taken by Dr Westley on that occasion are in the
following terms:
Update in setting of significant stressor, involvement with TEMHS
and Dr Britz.
Collateral history from Dad.
No suicidal ideation stated.Wanting to minimise medications
Management:
Continue Efexor 75mg (when script due)
Nil further medications
Supp Counselling/MI approach
Crisis management: Speak to parents, speak to aunty, reach for social
interaction with mates, go for a walk, call Lifeline/MHATReview next week (Wed/Thurs)
Actions:
Prescription added: EFEXOR-XR SR CAPSULE 75mg 75mg once daily
EFEXOR_XR SR CAPSULE 37.5mg ceased. Reason for cessation –
Completed without problems
Prescriptions printed:EFEXOR-XR SR CAPSULE 75mg 75mg once daily
Medicare item:
2713[6]
Doctor Westley said that his use of the word “continue” in the sentence
“continue Efexor 75mg (when Script due)” meant that she was already on
75mg at that point in time. However that evidence is in conflict with the
evidence of Dr Britz and Sabrina’s parents. To that point in time Sabrina
had been taking 37.5mg a day.
On 6 July 2017, Sabrina and her parents returned to see Dr Westley. The
notes of that consultation are in these terms:
Visit type:
Surgery Consultation
Sabrina describes deterioration in mood recent days. Has ceased
Efexor 75mg in morning (last 2 days). Suicidal ideation recently, no
clear plan. Able to action crisis plan through parents and engaging
friends.Feeling shaky, yawning, reduced energy, concentration pressure.
Reason for contact:
depression with anxiety
Management:
Agreed to:
(a) Continue Psychology (next Wednesday)
(b) Cease Efexor (c) Nil other medication
(d) Continue Body Balance at 7pm tonight
(e)
Review for holistic care tomorrow (include review for US and gynaecology topics tomorrow).
Medicare item:
36
Sabrina’s parents said that in the course of the consultation Dr Westley
commented that if he had commenced the treatment of Sabrina he would
not have prescribed Efexor. Mrs Di Lembo then sought advice as to
whether they should seek the assistance of a psychiatrist. Dr Westley
seemed dismissive in saying: “if you have $700 an hour to spend I can
give you the name of one in Palmerston”.
They thought the consultation ended awkwardly with Dr Westley
reprimanding Sabrina for missing an appointment the day before . They
did not take up the offer of another appointment and waited for the return
of Dr Britz.
At that point in time Sabrina had been seen by a General Practitioner at
the Tristar Group on five occasions in one month. A detailed history had
not been taken, the notes of her consultations remained inadequate and no
assessment tools had been utilised to assist in diagnosis or gauging the
severity of her symptoms.
During that period the psychiatrist in the Access Team at the Mental
Health Service had made a recommendation to the Tristar practice about
increasing the dose of Sabrina’s medication. That had happened and
Sabrina had taken the increased dosage for at least four days. However, in
the context of worsening symptoms including having suicidal ideations
she stopped taking the medication. Doctor Westley agreed with that
course. However he did not provide other options. He did not provide any
other form of treatment for her symptoms. He simply confirmed what she
was already doing as a management plan.
Perhaps more importantly, he did not communicate with Dr Chapman at
the Mental Health Service that the recommendations provided in the email
to him were not being adopted and that Sabrina had stopped taking Efexor
altogether. That became the subject of comment by one of the expert
psychiatrists that provided reports in relation to the management of
Sabrina. Dr Olav Nielssen said:
“In retrospect, Dr Chapman was clearly correct to recommend
increasing the dose of venlafaxine [Efexor] toward an effective level,
and the tragedy is that Ms Di Lembo stopped taking the medication
in the weeks before her suicide, before it could take effect.”
Dr Westley conceded that he should have contacted the Mental Health
Service for further guidance in relation to the treatment of Sabrina at that
point in time.[7]
The experience of Sabrina was that after being on Efexor for a month she
was deteriorating. She had taken Efexor on advice that it would remove her anxiety and allow her to continue her studies. However, rather than
experiencing improvement she was experiencing deterioration. Her
parents were deeply concerned.
On 12 July 2017, after the return of Dr Britz, Sabrina and her parents
went to see her. The notes of that consultation are in the following terms:
Visit Type
Surgery Consultation
Reason for Contact
Review
presents for review
things not good whilst I was not here
has stopped medication
changed to louise page at easafeels that this is working well
has decided to defer next semester
not sure how she feels about this
states she doesn’t care
was out on weekend
then crashedconcerned that there is something organic going on
would like a referral to dr mitchell about her periods
Management:
referred to jenny mitchell
continue with psychologistreview as needed
Actions:
Letter Created – re. Standard Referral Letter to DR JENNY
MITCHELL
Letter Printed – re. Standard Referral Letter to DR JENNY
MITCHELL
Medicare item:
44
That was the sixth and final interaction by the General Practitioners at
Tristar Group with Sabrina and her parents. The continued belief that
there was an organic issue was likely to be related to the fact that they
had tried anti-depressant medication that had not assisted.
Doctor Britz said at that consultation Sabrina and her parents were
resistant to trialling other medication because of their belief that Sabrina
had a reaction to the Efexor. That is again likely to have been due to a
belief that the deterioration in her mental state was due to the medication.
That same belief also seems to have been adopted by Dr Britz:
“At the time we did discuss further medication and Ms Di Lembo was
quite resistant to trialling anything further as she’d had reactions to
the medication I had prescribed. This is not uncommon.”[8]The adoption by Dr Britz of that explanation is likely to be at least in part
because she was unaware that the dose that she had prescribed was sub-
therapeutic. It was not until shortly before the commencement of the
inquest that she became aware of that fact. During the course of her
evidence she sought to defend the decision of dosage on the basis that
Sabrina was “of slight stature”. However when it was pointed out that
Sabrina was 70 kilograms she conceded that the dose should have been
the normal recommended dose.[9]
However, after that consultation there was no further contact between Dr
Britz and Sabrina or her family. Dr Britz told me that on the way out of
the premises there was an appointment made in two days’ time. However
there is no other evidence of that being the case. Dr Britz did not seek to
contact the psychologist involved in the treatment of Sabrina or the
Mental Health Service.
That same day (12 July) Sabrina saw the psychologist at EASA. It was
recorded that she was “very distressed no longer able to push self to get
done – trauma of identity”.
Also on that afternoon at 2.19pm a mental health clinician from the
Mental Health Service called. Sabrina told the clinician that she had “seen
Dr Britz and they have decided to cease the medication”. She said the
psychologist had been very helpful. The clinician made the following note
about that phone call:
“No pressure or poverty of speech and normal rate and volume.
Polite and engaging. States that she has been working on being clearer in her thinking and mood improved. Future focused and says
that she has improved since cessation of medication.”
The plan by the mental health clinician was to close the file. The clinician
did not communicate with Dr Britz or the psychologist. Dr Chapman
confirmed the closure of the file six days later.
There was one more contact with the psychologist on 26 July 2017.
Sabrina seemed to be improving at that consultation although it was
recorded: “a lot of philosophising and past regretting and then fear of
future”.
Sabrina said to her father:
“I’ve got this for life … if I can crumble over two stupid exams,
what about when I get married and I have kids, you’re going to be
worried for me for the rest of your life”.
To her parents, Sabrina seemed to improve somewhat. Her mother
continued to sleep in her room, but Sabrina was making some effort to
reconnect with friends, she was going to the gym and she made
arrangements to go with her friends to the Darwin Cup on 7 August 2017.
The night before the Cup Sabrina was concerned about what she would
wear, particularly the fascinator. She was still trying different fascinators
at midnight.
At 1.30am her mother went to Sabrina’s room. Sabrina was sitting at her
desk. When her mother entered her room she jumped up as if she didn’t
want her mother to see what she was doing. She put on another fascinator.
She told her mother to go to bed, that she was fine. Her mother said
goodnight. Sabrina hugged her and told her she loved her. It was the first
time in over two months her mother did not sleep in her room.
By 10.00am Sabrina hadn’t been seen. Her bathroom door was locked.
When her mother opened the door she found Sabrina hanging from the fan
by a length of rope. There was a note in her daily journal. It said in part:
“It all makes sense to me. It’s better that I am a memory to move on
from than a constant worry for the rest of their lives. I have to go and
hope one day I will be forgiven … it’s all my fault everyone has done
the best they can”.
Issues
A number of expert reports were obtained and tendered in evidence during
the inquest. The issues raised included:
a. The failure of the Mental Health Service to take a detailed history and undertake a proper assessment, including a face to face
assessment with Sabrina;
b. The failure of the psychiatrist to speak with Mrs Di Lembo;
c. The failure of the GPs to take a detailed history and undertake a proper assessment;
d. The failure to use assessment tools such as K10, GAD7, DASS to assist in gauging the severity of the symptoms and to assist with
diagnosis;
e. The failure to make a diagnosis;
f. The failure to take appropriate notes;
g. The failure to prescribe a therapeutic dose of Efexor;
h. The failure to undertake a review of Sabrina after her stopping taking the anti-despressant;
i. The failure of both GPs to refer Sabrina to a psychiatrist; and
j. The failure to coordinate the care of Sabrina.
During the last nine weeks of her life Sabrina had seen or spoken to
medical providers over the phone on 17 occasions. Her mother had more
than 20 interactions with the medical providers.
During that period no adequate detailed history was taken. At no time was
she properly assessed. At no time was she asked to undertake formal
testing to assist in determining the severity of her symptoms or diagnosis.
At no time was she appropriately diagnosed.
After her death expert psychiatrists suggested possible diagnoses. Two
experts were of the opinion that she suffered from melancholic
depression. A third psychiatrist thought she had an anxiety disorder.
However they did not have the benefit of an adequate history or
assessment in forming those opinions.
What is abundantly clear is that during the course of those nine weeks no
person at the Mental Health Service set eyes on either Sabrina or her
mother and the General Practitioners did not take the time to make an
appropriate assessment or refer her to the Mental Health Service or a
private psychiatrist for that purpose.
Notetaking
The notetaking by the health practitioners was and was conceded to be
very poor.
Dr Britz said:
“I concede that my note-taking, note-keeping is quite poor. It's not
up to the standard that you would expect for a written psychological
assessment and it is something that I have endeavoured to improve
on”.10
Dr Westley didn’t think the notes of Dr Britz were adequate.[11] He
conceded his own notes were also lacking:
“… unfortunately and clearly, I should have written much more
regarding the nature of the consultation”[12].
When asked about the level of detail (specifically whether he should have
recorded the dosage of Efexor Sabrina was on prior to the consultation),
Dr Westley said:
“If I sought to get that level of information on every single patient I
would only be able to see five patients a day”. [13]
If that is the case, I encourage Dr Westley to reconsider his priorities and
the manner in which he conducts his practice.
Lack of Transparency about Level of Training
Any person can look up the status of Health Practitioners on the
Australian Health Practitioners Regulation Agency (AHPRA) website.
The entry for Dr Britz next to “Registration type” is “General”.
What is not so intuitive is that to have a provider number to access
Medicare a General Practitioner needs to be a specialist General
Practitioner or part of a training scheme to obtain that specialty. If that
specialty is obtained the AHPRA website will list a further “Registration
type” as “Specialist”.
That in effect indicates that the doctor has successfully completed their
examinations to become a fellow of either the Royal Australian College of
General Practitioners (RACGP) or the Australian College of Rural and
Remote Medicine (ACRRM).
There is no readily available information of the status of a doctor’s
progression in training prior to obtaining the specialisation. There are, it
seems, a considerable number of pathways and programs to assist doctors
in completing that specialisation. They form a maze that is not easy to
navigate.
The relevance is that it was not until the first day of the inquest that the
parents of Sabrina were aware that Dr Britz did not have fellowship of
either of the Colleges. It was the first time that they were aware that Dr
Britz had not been able to pass her examinations on at least five occasions
to obtain the “Specialist” label.
Doctor Britz indicated that she was a “Registrar GP” and has been since
2009. That she was a “Registrar” rather than a specialist General
Practitioner was not known to Mr and Mrs Di Lembo when they accepted
the recommendation of the Mental Health Service to change their GP and
consult Dr Britz. It was not known to them during the consultations with
Dr Britz.
The Responses
Dr Kara Britz
Doctor Britz indicated that she is a “General Practitioner in training”. She
entered the training program in 2009 and said that she is a “GP registrar
in the Rural Locum Relief Program”. She said she no longer needed direct
supervision but had a mentor with whom she spoke. Doctor Britz said she
had an interest in mental health.
Dr Britz conceded that she should have taken a detailed history, that she
should have used common assessment tools such as the K10 or DASS and
that her consultation notes were very poor. She said most of the
information she provided was from her memory.
She said that had she known that when Sabrina saw her on 7 June 2017
she had already seen another GP about her mental health on two occasions
she would have referred her to the Access Team of the Mental Health
Service (MHAT). She said that was preferable because in her experience
patients are seen a lot sooner that way than if referred to a private
psychiatrist. She said that she accepted that the dose of Efexor prescribed
was sub-therapeutic.
Dr Britz said she had made significant changes to her practice since the
death of Sabrina.
Dr Bernard Westley
The only medical provider that didn’t provide a response prior to the
inquest was Dr Westley. Nor did he attend the inquest in response to the
Summons served upon him until after I provided him with the invitation
to either attend of his own volition or be brought in by the Police.
One of the experts, Dr James Lynch, was of the opinion that Sabrina
“required treatment which was outside the scope that a general
practitioner could have provided. She required urgent specialist
intervention by a psychiatrist.” Dr Westley was asked about that
opinion:
Q. I think what this witness [Dr Lynch] is suggesting is that you should have referred her to a psychiatrist?
A. In urban Melbourne that would be excellent advice. I would disagree with that advice in Darwin or in any NT area.
That was in contrast to the evidence of Dr Britz who conceded that she
should have referred Sabrina to the Mental Health Team after the first
consultation.
However in later correspondence Dr Westley wrote about his attendance
on Sabrina on 6 July 2017 in these terms:
“I did not see a need to refer Sabrina back to the MHAT that day as I
confirmed that she intended to again see her psychologist the
following week. However, with hindsight it would have been wise for
me to contact the MHAT that day for guidance.” [14]
Dr David Chapman
Dr Chapman provided two statements. The first was filed on 15 October
2018. In that there were few concessions made. However, having listened
to the evidence on 23 October 2018, Dr Chapman provided a
supplementary statement. In the second paragraph of that statement he
said:
“I regret that my refusal to speak to Lidia has caused her and her
family distress. I apologise. I acknowledge I should have made the
effort to find the time to speak to Lidia or more particularly
Sabrina.”
Dr Chapman agreed that there should have been more engagement of the
Mental Health Service Access Team after contact was made on 7 June
2017. He said he was away on that day but that a clinician should have
seen Sabrina face-to-face. He considered that depending on the
recommendation of the clinician he could then have personally seen
Sabrina on his return. Dr Chapman apologised to the family of Sabrina forthat not happening.[15]
He accepted that given the interactions of the Mental Health Service with
the Di Lembo family that it was reasonable for them to have the view that
the Mental Health Service was assisting in the care and treatment of
Sabrina.[16]
Dr Chapman agreed that there was no coordination of Sabrina’s care. He
thought that the primary responsibility lay with the General Practitioners
however he accepted that the involvement of the Mental Health Service
should not have been terminated without obtaining notes of at least the
last attendances by Sabrina on the other providers.
He accepted that if that had occurred the file would not have been closed
and it is likely that a face-to-face consultation would have been had with
Sabrina at that point. He said that he would institute a procedure to ensure
that happened in all cases prior to closure.
Top End Health Service
The response for the Top End Health Service was provided by Mr Richard
Campion the General Manager for Top End Mental Health and Alcohol
and Other Drugs.
Mr Campion indicated in his response that opportunities were missed for
Sabrina to be provided with a face-to-face assessment. He was of the
opinion that if the opportunities had not been missed the family would
have “experienced much easier pathways to the relevant support and
advice”. He believed that with the changes made since the death of
Sabrina, a person in similar circumstances would now receive a face-to-
face assessment.
He indicated that there were a plethora of policy reviews and changes. On
that point the following exchange took place:
Coroner: Policies are worth nothing unless they're enforced, aren't
they?
Campion: That's right, your Honour, I agree fully.
Coroner: And one of the ways to get them enforced is to do regular
audits so you can slap people who aren't following the
policies?
Campion: That's right, your Honour.
Coroner: And you're going to be doing that, aren't you?
Campion: We are, your Honour, yes.
There were some changes made that are particularly relevant to the
circumstances surrounding the difficulties Sabrina and her family
experienced. For instance, from August 2018 there has been a mandated
requirement to use a pro forma triage form for the initial assessment,
whether that be by telephone or face-to-face.
There has been a revision of the procedures that ensure that clients are
routinely asked about consent to share information with family members.
That is hoped to overcome the reservations that may have in part
contributed to the refusal of Dr Chapman to speak to Mrs Di Lembo.
Mr Campion indicated that the referring of patients to particular GP’s
would cease.
The Top End Health Service provided a number of undertakings in the
following terms:
a. “The Top End Mental Health Service will expressly confirm with the consumer and referrers whether it is the primary health care
provider.
b. If the Top End Mental Health Service is not acting as a primary health care provider then it will not adjust or make recommendations
to adjust medications without a request or a referral from the primary
health care provider, or that a face-to-face assessment with the
consumer.
c. If Top End Mental Health Service assumes the role of the primary health care provider for a consumer it will communicate that fact to
all known stakeholders.
d. A case will not be closed until all known stakeholders have been communicated with and Top End Mental Health Service is satisfied
that it’s appropriate to do so.
All of the above undertakings will be embedded in procedures and
audited to ensure compliance.”
Suggestions by family
Counsel for the family made impassioned submissions in relation to
changes that should be made to the Mental Health Service. It is clear that
the Di Lembo family have put a great deal of thought and consideration
into those submissions. For that reason I have annexed the bulk of those
to these findings.
However, the Coroner’s role is not to determine matters of policy, the
preferred model for care or the best allocation for the resources. Those are
matters for Government.
Section 34(2) Coroners Act does provide that I may comment however:
“A coroner may comment on a matter, including public health or
safety or the administration of justice, connected with the death or
disaster being investigated”.
Comment
Top End Mental Health Service
As indicated during the course of the inquest, the NT is not and never has
been well serviced by private psychiatrists and those that are in the NT
are very busy. That provides challenges particularly for the Mental Health
Service that shoulders a relatively larger proportion of the cases compared
to other jurisdictions.
That appears to have been managed to some extent by deflecting clients
from the service to General Practitioners. That is what happened in this
case. The Mental Health Service on receiving the telephone call from the
very concerned mother told her to take her daughter to a GP and gave her
the name of one they recommended. They did so without seeing either
Sabrina or her mother.
Having done that however they maintained some minimal involvement.
They called to check how things were going. They even corresponded
with the GP Practice about increasing the dose of the anti-depressant. The
level of their involvement however was at best confused. So much so that
there was no agreement within the Mental Health Service as to whether
Sabrina was a client or not.
The most crucial aspect however, was the expectations their involvement
gave to Sabrina and her mother. Mrs Di Lembo was given ample reason to
believe that the expertise of the Mental Health Service was being utilised
to oversee the care and treatment of Sabrina.
But for that belief there is little doubt that Mr and Mrs Di Lembo would
have taken other action to obtain expert assistance for Sabrina. However,
despite their many contacts with Sabrina and her family the Mental Health
Service did not oversee her care and treatment.
The Top End Mental Health Service provided undertakings at the end of
the inquest. They are primarily aimed at ensuring those aspects are
remedied:
a. Any referral to a GP is made on an appropriate basis. That would require an appropriate and comprehensive assessment that may
well include a face-to-face assessment;
b. There is a proper and considered decision about the role that the Mental Health Service will play;
c. The decision about that role is communicated to everyone concerned, including other providers and the family; and
d. The involvement does not cease without first taking appropriate steps to check with other providers involved in the care and
treatment of the client.
If that had happened in the case of Sabrina’s care there were a number of
critical points at which there would have been an opportunity for the care
and treatment to have taken a different path.
General Practitioners
Having referred Mrs Di Lembo and Sabrina to a GP the care and treatment
provided was significantly below the level that Sabrina and her family
were entitled to expect.
No detailed history was taken. Common sense would suggest that as a
first step. It is a necessary precursor to assessment. It was also an
expectation of the Medicare scheme. The explanation to Medicare item
44(a) is “taking an extensive patient history”. The explanation to
Medicare item 36(a) is “taking a detailed patient history”. The
explanation to Medicare item 2713 in part involves “taking relevant
history and identifying the presenting problem”.
100. No proper assessment of Sabrina was undertaken. That is surely a
necessary precursor to treatment. As it turned out the chosen treatment,
prescribing an anti-depressant, was ineffective because it was half the therapeutic dose. Her continuing deterioration was then thought by her
family and both the GPs to be at least in part related to the anti -
depressant. In those circumstances neither GP saw the need to contact the
Mental Health Service for either referral or guidance when Sabrina
stopped taking the anti-depressant.
101. It is possible that the anti-depressant was having an effect upon Sabrina.
However, whether that was the case or not there was an urgent need for
some other form of treatment. She was significantly worse than when she
had first been seen a month before. She had experienced suicidal ideation.
A week later she appeared to have given up and no longer cared about her
education.
102. However, neither GP advocated any other treatment. They left her with
the same plan she was on while deteriorating, excepting that they agreed
that the anti-depressant medication could cease. Neither saw the need to
contact the Mental Health Service in the context that but a week or so
before that service had recommended increasing the anti -depressant.
103. The question of course is what system needs to change to ensure that GPs
take an extensive history, undertake a proper assessment, understand
appropriate drug dosage[17] and recognise when referral to a specialist
mental health service is required.
104. Training or experience of the GPs appeared to be lacking. That was most
plainly displayed in the failure to appreciate that the 37.5mg Efexor was a
sub-therapeutic dose. That led to Sabrina and her mother waiting for a
change they were told would come after the medication had time to take
effect. They waited and Sabrina deteriorated. That was attributed to the
medication. They lost faith in the medication. That may have been able to
be restored if it had been recognised that Sabrina had not been providedthe correct dose.
105. Crucially in waiting for something that was not going to happen, Sabrina
lost hope of ever being able to function without the severe levels of
anxiety she was experiencing.
106. There also seemed a less than satisfactory understanding of their role in
the coordination of care. There was none. That was particularly evident on
12 July 2017 when she saw or spoke to the three providers involved in her
care and treatment: Dr Britz, EASA and the Mental Health Service. She
gave a different account of herself on each occasion.
107. It was urged upon me by Counsel for the family during the course of
submissions that I refer the GPs to the Medical Board. As I commented at
the time. It is not necessary that I do so as that can be done by anyone
including the family and their counsel.
108. The care and treatment of Sabrina was a heart wrenching story of missed
opportunity after missed opportunity. Her parents involved themselves in
her care to the point of becoming a nuisance to the health practitioners in
their attempt to convey the severity of their daughter’s condition. Dr
Chapman even instructed that Mrs Di Lembo be told to “stop trying to be
a doctor”. Perhaps it is too easy to criticise that remark. But in
circumstances where neither Dr Chapman, nor any other doctor or
clinician employed by the Mental Health Service had seen Sabrina or her
mother it was breathtaking.
109. Pursuant to section 34 of the Coroner’s Act, I find as follows:
(i) The identity of the deceased was Sabrina Josephine Di Lembo
born on 5 May 1998, in Darwin, Northern Territory, Australia.
(ii) The time of death was prior to 10.00 am on 7 August 2017. The
place of death was 40 Charlotte Street, Parap in the Northern
Territory.
(iii) The cause of death was self-inflicted hanging.
(iv) The particulars required to register the death:
1. The deceased was Sabrina Josephine Di Lembo. 2. The deceased was of Caucasian descent. 3. The deceased was a student at law at the time of her death. 4. The death was reported to the Coroner by the deceased’s brother.
5. The cause of death was confirmed by Forensic Pathologist,
Dr John Rutherford.
6. The deceased’s mother was Lidia Maria Di Lembo and her
father was Michael Di Lembo.
Recommendations
110. I recommend that the Top End Mental Health Service ensure that all
clients are properly assessed before making a decision to refer their care
and treatment to a General Practitioner.
111. I recommend that the role of the Top End Mental Health Service in the
care and treatment of clients is explicitly stated to the client and if
applicable the client’s family or significant other person.
112. I recommend that the Top End Mental Health Service have a specific
procedure to ensure that where any responsibility is retained by the
Service for care and treatment, or the monitoring of care and treatment,
that there be a proper coordination with all relevant providers.
113. I recommend that before the involvement of the Top End Health Service
ceases that it ensures that that all other relevant providers are contacted
and copies of their last consultations obtained.
114. I recommend that the Medical Board remind all General Practitioners of
the care and attention required and the obligation to take a detailed
history, undertake an appropriate assessment and take proper notes when
dealing with clients presenting with mental health concerns.
Dated this 3rd day of December 2018.
_________________________
GREG CAVANAGH
TERRITORY CORONER
Annexure
Your Honour, Sabrina’s family based on a lived experience as survivors of a
family impacted by suicide, have suggested the following be read on to the
record as their official suggestions for improvement.
That a one-stop shop be established for adolescents up to the age of 25, experiencing any form of mental condition or illness. All should be seen face to face for a period of at least four to six weeks, particularly if medication is prescribed. This service can then refer or recommend other qualified professionals to continue the care of the patient.
However, the service ultimately should be responsible for monitoring progress and the coordination of treatment. We suggest this for adolescents specifically because they are the most vulnerable in our society and do not have the life
experience to deal with anxiety, depression and other mental illnesses without
careful and clear treatment pathways.
Next, that general practitioners should not be allowed to prescribe antidepressant medication to adolescents without consulting a psychiatrist, albeit even interstate or on the phone if necessary. There has to be communication.
Next, that general practitioners should not change medication dosage for adolescents without the consulting of a psychiatrist.
That the Northern Territory Public Health Network, the AMA, and the
Northern Territory Government create the opportunity and incentive for
interested GPs to attend intensive ongoing professional training in mental health
and treatment planning. They would then be identified on a publicly available
list to any member of the public who wishes to source a general practitioner with
specialisation in mental illness and treatment. The public need this.
That the Department of Health explore how to incentivise the Commonwealth to increase remuneration or fees for general practitioners who treat patients with mental illness so that proper time and care can be dedicated to patients to ensure appropriate clinical pathways and an integrated continuity of care.
That patients on antidepressants be asked to give consent for their general practitioner to discuss and share information with psychiatrists and a psychologist if one is engaged.
That the Northern Territory Government approach and fund headspace to expand its current model of service delivery for adolescents experiencing mental illness.
That a family support group be funded and established for those caring and supporting family members with a mental illness. Families are really left to fend for themselves and navigate the system at a critical time without clear understanding, knowledge and pathways to help loved ones experiencing mental illness.
That the Department of Education should introduce mental health awareness in schools for teachers and students from at least year 10 to prepare students on how to deal with anxiety and depression and to build resilience. This should be continued into university with resources allocated. The counselling service at
Charles Darwin University is underfunded. When Sabrina’s mother called them
to request a counsellor she received a call back two weeks later. She was then
told they didn’t have the capacity anyway.
The Department of Education and the Department of Health should collaborate and develop information for parents in understanding mental illness. How to care for children who may experience anxiety and depression, understanding antidepressant medication and the management of this and referral pathways should they need additional support.
That all health professionals treating young people with anxiety and depression
should be asking young people different questions to “are you suicidal” to assess
risk. A young person doesn’t understand what that means. Are they in pain?
Can they describe it? Do you want it to stop? Young people do not think the same way adults do and language should be tailored accordingly.
That there should be a coordinated, collaborative and joined up mental health model of care developed in the Northern Territory for adolescents and adults suffering from mental illness. Most professionals are currently working in
isolation and no one is taking accountability or responsibility to holistically manage a patient. This could result in better clinical services and outcomes.
The risk assessment by the Mental Health Service to provide clinical care should
be reviewed and it’s acknowledged that this has been a central focus and has
already begun. A focus on risk, your Honour, does not appear to indicate who
may or may not be suicidal and diverse services from high quality clinical care,
genuine engagement with an individual and with their circumstances.
That the Department of Health develop guidelines and policy for staff on how to effectively engage and communicate with private GPs and psychologists so tha t community and continuity of care is clear and delineated, including escalation
strategy and joint supervision to ensure the best possible outcome for patients.
That evidence-based mental health training should be regularly offered to help all services in suicide prevention and intervention that are delivered by government, private and non-government sectors.
professionals, educators, counsellors, to increase awareness and reduce the
stigma of mental illness. The family recommends that the Black Dog Institute be
considered for this.
That calls by patients and carers to inform the Mental Health Service be recorded so that other practitioners involved can listen to the calls and hear information first-hand. This also ensures, your Honour, that there will be an accurate record of all phone calls for the service.
And finally, that the Coroner’s Office, your Honour, in collaboration with the
relevant agencies should closely audit and monitor the progress of the key
findings and recommendations in a meaningful way to ensure that identified gaps
and improvements are not lost in translation.
1. The explanation of Medicare Item 44 is in these terms:
Item 44: Professional attendance by a general practitioner (not being a service to which any other item in this table applies) lasting at least 40 minutes, including any of the following that are clinically relevant:
a) taking an extensive patient history;
b) performing a clinical examination;
c) arranging any necessary investigation;
d) implementing a management plan;e) providing appropriate preventive health care;
in relation to one or more health-related issues, with appropriate documentation.
[2] Otherwise known as Venlafaxine.
[3] The explanation of Medicare Item 36 is similar to Item 44 however for a shorter period of
time. It is in these terms:
[5] Transcript p 15
[6] The explanation of Medicare Item 2713 is in these terms:
Item 2713: Professional attendance by a general practitioner in relation to a mental disorder and of at least 20 minutes in duration, involving taking relevant history and identifying the presenting problem (to the extent not previously recorded), providing treatment and advice and, if appropriate, referral for other services or treatments, and documenting the outcomes of the consultation.
[7] Submission by Dr Westley dated 31 October 2018
[8] Transcript p 23
[9] Transcript p 28 10 Transcript p 14
[11] Transcript p 41
[12] Transcript p 42
[13] Transcript p 47
[14] Submission dated 31 October 2018, paragraph 7
[15] Supplementary statement, paragraph 3
[16] Transcript p 112
[17] Those comments should not be taken as an endorsement of the use of anti -depressants in
this case. However, having chosen that course it was incumbent upon the GPs to ensure that
the dose was appropriate to bring about the desired effect.
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