Darwin teen Sabrina Di Lembo ‘lost hope’ because of NT health system failures, inquest told
The suicide of a Darwin teenager is a “heart-wrenching” story of missed opportunities and failures by GPs and other medical professionals, a coroner has found.
- Sabrina Di Lembo’s doctors lacked experience and training, inquest into her death finds
- Top End Mental Health Service and GPs failed to properly assess the Darwin teenager
- Medical Board should remind GPs of their obligations, coroner recommends
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Sabrina Di Lembo, 19, took her own life in August 2017 after experiencing serious anxiety and panic attacks in the lead-up to university assessments and exams.
In the last nine weeks of Sabrina’s life, she had contact with Northern Territory health professionals on 17 separate occasions — and her mother Lidia had more than 20 interactions.
“The care and treatment of Sabrina was a heart-wrenching story of missed opportunity after missed opportunity,” coroner Greg Cavanagh said in his findings, delivered on Monday.
The coroner found that during this nine-week period, nobody from the Top End Mental Health Service had a face-to-face consultation with Sabrina.
The GPs at Tristar Medical Group, Dr Bernard Westley and Dr Kara Britz, did not take the time to assess Sabrina properly or refer her back to the mental health service or a psychiatrist, the coroner said.
Sabrina was initially given half the recommended dose of the anti-depressant Efexor by Dr Britz, a “crucial” failure among many highlighted by the coroner.
“Training or experience of the GPs appeared to be lacking,” he said.
“That was most plainly displayed in the failure to appreciate that the 37.5mg Efexor was a sub-therapeutic dose.”
Sabrina and her parents then mistakenly believed the anti-depressants would start working, he said.
“They waited and Sabrina deteriorated,” the coroner found.
“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.”
Mother told to ‘stop trying to be a doctor’
The coroner said there were several critical points where Sabrina’s care could have taken a “different path”, including after the GPs discovered she had stopped taking Efexor.
“The care and treatment provided was significantly below the level that Sabrina and her family were entitled to expect,” he said.
At the time, Lidia Di Lembo had been sleeping in her daughter’s room each night and had taken carer’s leave from work.
“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,” the coroner found.
There was a “breathtaking” lack of empathy from Top End Mental Health psychiatrist Dr David Chapman, the coroner said, who has since apologised for not arranging a face-to-face meeting with Sabrina or her mother.
Dr Chapman instructed staff in an email to tell Lidia Di Lembo she should “stop trying to be a doctor”.
Sabrina’s parents, Lidia and Michael, spoke outside court after reading the coroner’s findings.
“I was just gobsmacked, and it’s like how dare he?”, Lidia Di Lembo said.
“Parents know more than anybody what their kids are going through and I was repeatedly asking questions, as any good parent should.”
“We expected more from those health professionals, starting from the mental health service and the GPs to actually properly assess Sabrina.”
Psychiatrist referral for ‘urban Melbourne’, doctor said
The coroner described the notetaking of both GPs as “very poor” and reflected on Dr Westley’s excuse for not properly recording Sabrina’s prior anti-depressant dosage.
“If I sought to get that level of information on every single patient, I would only be able to see five patients a day,” Dr Westley told the inquest.
The coroner said: “If that is the case, I encourage Dr Westley to reconsider his priorities and the manner in which he conducts his practice.”
The Di Lembos said they were considering whether to refer the case to the appropriate regulatory bodies and if legal action would be a worthwhile pursuit.
“Taking further action, would it improve the system?” Michael Di Lembo said.
“That’s the key, we’re not about the money — it’s about improving the system and making people accountable and responsible in the future, if we go down that path.
“My lovely daughter’s not coming back.”
Mr Di Lembo said he was appalled to hear Dr Westley’s evidence during the inquest that referral to a psychiatrist was appropriate advice for “urban Melbourne”, but not the Northern Territory.
“How can that come out of a doctor’s mouth? That’s my decision,” he said.
“You tell me what I need to know … Then I take my daughter to Melbourne, to anywhere in the world.”
Recommendations will be ‘taken seriously’
The coroner has recommended that the Top End Mental Health Service ensure all patients are properly assessed before referring them to GPs, and that the service better explain its role to patients and coordinate its care with other providers.
Coroner Cavanagh has also asked the Medical Board of Australia to remind all GPs of their obligation to take a detailed history and a proper assessment with notes when patients present with mental health concerns.
“I call upon the minister and this government to ensure that those changes are made and to monitor those changes,” Mr Di Lembo said.
“We look forward to the minister’s response on this because we don’t want all this that we’ve done here to be lost in the paperwork.”
Lidia Di Lembo said there needed to be more compassion among Northern Territory health professionals for young people with mental health issues.
“So that when a Sabrina turns up, who actually is struggling, genuinely struggling, that there is more effort into caring and treating these young people,” she said.
“That did not happen with our daughter.”
Michael and Lidia Di Lembo said there needed to be more compassion among NT health professionals (ABC News: Felicity James)
In a statement, Northern Territory Health Minister Natasha Fyles said her thoughts were with the family and friends of Sabrina.
“The coroner’s findings will now be referred to the Department of Health to respond to the recommendations,” she said.
“I would like to reassure the Di Lembo family that these recommendations will be taken seriously.”