Finding into death of Katarina Sonia Novakovic

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2010 003708

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, PARESA ANTONIADIS SPANOS, Coroner,

having investigated the death of KATARINA SONIA NOVAKOVIC without holding an inquest: find that the identity of the deceased was KATARINA SONIA NOVAKOVIC born on 8 April 1963, and that the death occurred on 25 September 2010 at 3 Gladys Street, Nunawading Victoria 3131 from: l(a) INCISED INJURY TO THE NECK.

Pursuant to section 67(2) of the Coroners Act 2008, I make findings with respect to the following circumstances:

1. Ms Novakovic was a 47 year-old single woman who resided at the above address. Ms Novakovic worked until she was 21 years old when she developed symptoms of social anxiety and had been unable to work since. Ms Novakovic’s mother died in 2008, her father died in 2009 and her only sister was also deceased. Ms Novakovic lived with her parents until their deaths, then continued to live alone in the family home. Ms Novakovic’s medical history included obesity, non-

insulin dependent diabetes and ingrown toenails.

Psychiatric History

px Ms Novakovic’s first recorded mental illness episode was in 1983, when she was diagnosed with schizophrenia. Ms Novakovic had five inpatient admissions since that time and received intermittent case management from Eastern Health community mental health services, mainly Box Hill Koonung Clinic. Ms Novakovic was compliant with her medication and generally remained

well for long periods, preferring to have her care provided by private psychiatrists and general

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practitioners. Ms Novakovic had a fixed delusion that was the focus of her life. She attributed her illness to being hypnotised in Bourke, NSW, and expressed a desire to return to Bourke to cure

herself.

3. Dr Alan Blandthorn had been Ms Novakovic’s consultant psychiatrist from 15 May 2007.

Dr Blandthorn reported that her principal reason for attendance was to obtain prescriptions for the antipsychotic Olanzapine and believed that she had benefitted from it. However, Ms Novakovic’s attendance at appointments was always erratic. Following the death of Ms Novakovic’s father in February 2009, Dr Blandthorn discussed with her how living on her own may be extremely difficult and asked her to consider some form of supported accommodation. Dr Blandthorn saw Ms Novakovic again in July 2009 where it was arranged to meet with her case manager and Dr Blandthorn to discuss her accommodation issues, but Ms Novakovic failed to attend the appointment made. Dr Blandthorn’s last contact with Ms Novakovic was on 12 January 2010. Ms Novakovic had purchased a car and intended to have a friend drive her to Bourke in April 2010 (Ms Novakovic later decided to cancel this trip). Her care was transferred to the Box Hill Mobile Support and Treatment Services (BHMSTS) up to the time of her death, though Ms Novakovic considered that she did not need substantial support since she had gained access to her parents’

estate.

4. Ms Novakovic spent most of her time alone in her home. BHMSTS had attempted to increase support services for her, including increasing social activities and engagement, but Ms Novakovic remained reluctant. Between July 2009 and February 2010 Ms Novakovic resided at

Carrington Supported Residential Service in Vermont.

5. Ms Novakovic did not have a sustained history of self-harm or suicide attempts, but had attempted suicide once in September 2008, when she impulsively and intentionally drove her car

into a tree.

6. The medical records show comprehensive, responsive and timely care was provided by both public and private practitioners involved in Ms Novakovic’s care, with sound communications of care plan and re-engagement processes. There was a shared care arrangement between Koonung Centre public psychiatrist Dr Jaideep Thoduguli and private psychiatrist Dr Blandthorn. Although Ms Novakovic had not consulted with Dr Blandthorn since 12 January 2010 it is clear in both Dr Blandthorn and the Box Hill Hospital’s medical records that there was ongoing and recent

consultation and communication regarding treatment.

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Zz The treatment for Ms Novakovic’s mental illness was pharmacological and a review of the previous year’s file indicates medications were prescribed according to clinical and prescribing guidelines. Over the years of treatment, there is evidence of medication changes being made to reduce the side effects experienced by Ms Novakovic, with a high level of support and monitoring provided to Ms Novakovic and her private practitioners by BHMSTS, keeping her well. The level

of support was clearly increased following her parents’ deaths.

ve Ms Novakovic had told Dr Blandthorn she was feeling lonely and they discussed an antidepressant as early as February 2009. Ms Novakovic was not seeing Dr Blandthorn or following through with various support plans. She reported feeling exhausted and finding it difficult to run her home day-to-day, as well as insomnia. Ms Novakovic had increasing plans to go to Bourke in October 2010 as she felt she might die soon. Ms Novakovic reluctantly agreed to try the antidepressant Escitalopam with increased contact and monitoring by BHMSTS. Escitalopam was prescribed for Ms Novakovic on 10 September 2010 and the script delivered to her on 11 September 2010. It is unknown when Ms Novakovic filled the script but she did have a box of

Escitalopam in her home at the time of her death.

Days before Ms Novakovic’s death

8. In the days before her death, Ms Novakovic had advised her case manager, neighbour and several friends that she missed her parents at home, needed a break and intended to hire a car (as she did not want to drive her manual car a long distance) and take a trip to Benalla to stay in a

caravan park for several weeks.

9. On 23 September 2010 Ms Novakovic’s case manager, Mrs Anh Nguyen, performed a home visit after she had spoken to her on the phone. Ms Novakovic said she did not want a home visit, but Mrs Nguyen wanted to complete a face-to-face review before Ms Novakovic left for her holiday. Mrs Nguyen completed a mental state examination and risk assessment assessed as stable.

Mrs Nguyen stated that Ms Novakovic denied any self-harm, suicidal or homicidal thoughts but did

have fluctuating helpless and hopeless themes such as life is not worth living.

10. Mrs Nguyen spoke to Ms Novakovic about her holiday, advising her to take some rest during her driving and provided her with information she might need including accommodation details as well as triage and hospital numbers in Benalla. Mrs Nguyen advised Ms Novakovic to contact Wodonga triage during her stay if needed, and Mrs Nguyen contacted Wodonga triage to inform them that Ms Novakovic would be on holiday in the catchment area for 4-6 weeks. With Ms

Novakovic’s consent, relevant triage information was also faxed to Wodonga.

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11. On 23 September 2010 Ms Novakovic hired a car and paid for rental of the vehicle until 26 October 2010. On Friday 24 September 2010, Ms Novakovic told her neighbour, Ms Margaret Hewawissa, that she was going to Benalla and asked her to collect her mail. Ms Novakovic explained that she had paid all her bills in advance and that Ms Hewawissa could have her

newspapers that were going to be delivered whilst she was away.

12. At about 8.00am on Saturday 25 September 2010 Ms Hewawissa visited Ms Novakovic to find out what time she would be leaving. She saw the hire car in the driveway and knocked on the door but there was no answer. Ms Hewawissa tried to telephone Ms Novakovic but there was no answer. Ms Hewawissa returned to the back of Ms Novakovic’s home in the afternoon with another neighbour, but got no response. Ms Hewawissa noticed groceries and other items in the back of the

hire car and was concerned that Ms Novakovic might still be in the house, so she telephoned police.

13. Police visited Ms Hewawissa and spoke to her at about 9.00pm, then went with her to Ms Novakovic’s home. Police forced a window open, entered the house and located Ms Novakovic lying on her back in the centre of the kitchen floor. There was a large pool of blood around her head and upper body, a large cut to her throat, and it was clear that she was deceased. A knife was located on the floor near Ms Novakovic’s right hand. Police found the hire car parked in her driveway with groceries, bags containing clothing and other items associated with going on holiday.

Reminder notes were located in the house stating ‘recharge mobile’, ‘turn off hot water’, ‘empty fridge’ and other tasks. A rubbish bin in a bedroom contained empty medication packets and various packets of medication were on top of a bedside table in the room, Police concluded that

there were no suspicious circumstances.

14. An autopsy was performed by Forensic Pathology Registrar Dr Julie Anne Teague from the Victorian Institute of Forensic Medicine (VIFM) who reviewed the circumstances as reported by the police to the coroner and provided a detailed written report of her findings. Dr Teague attributed death to incised injury to the neck and noted that toxicological analysis of blood revealed Olanzapine at ~0.2mg/L which is consistent with Ms Novakovic’s known medications. The level is also consistent with clinically derived therapeutic levels. Dr Teague noted that there were no identifiable incised injuries to the hands or forearms. The anterior neck is in a position accessible

to the deceased.

15. I find that Ms Novakovic intentionally took her own life by incised injury to the neck.

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COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments connected

with the death:

1. There is evidence of Ms Novakovic’s deteriorating mood which was treated by the BHMSTS by prescribing Escitalopam. BHMSTS completed a risk assessment, arranged timely consultant psychiatrist reviews and timely treatment change. There is no evidence her schizophrenia had exacerbated or that she was not taking the Olanzapine as prescribed. Whilst Ms Novakovic did not have a sustained or recent history of suicide attempts, the single attempt in 2008 was impulsive

and serious.

2. Ms Novakovic had made decisions leading up to her trip such as renting a car to avoid driving her manual car to Benalla, shopping for food staples and packing her car, and completing items on her ‘to do’ list. It appears that she may not have commenced the antidepressant and there was no recorded enquiry from Mrs Nguyen, although this may not have resulted in the lessening of

any impulsive suicide act.

3. The previous suicide attempt made by Ms Novakovic had been in the context of her being overwhelmed by the responsibility of caring for her parents. In addition, Ms Novakovic had in the years since her parents’ deaths arranged or spoken about arranging trips to Bourke on several occasions and had decided not to go or cancelled because she was physically unwell. It is possible that this trip to Benalla was going to take place and the anxiety associated with follow through and being by herself in a place where she knew no one may have been overwhelming for Ms Novakovic. There is evidence Ms Novakovic was contemplating her future accommodation options

which she was planning to address when she returned.

4, Icommend BHMSTS for their sustained high quality of care provided to Ms Novakovic, particularly with respect to the public/private service communication and shared care. However, the antidepressant was prescribed to Ms Novakovic and there appears to have been no attempt to assess

its effectiveness, assuming that Ms Novakovic was taking it as prescribed.

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RECOMMENDATION

Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation

connected with the death:

1. That to increase the safety of patients with an emerging depressive illness, Eastern Health Mental Health Services review its policy and clinical guidelines to ensure monitoring of therapeutic effectiveness in the high-risk commencement period for antidepressants is assessed according to best practice principles.

I direct that a copy of this finding be provided to the following:

Mrs Snezana Derbogosian

Dr Jenny Babb, Eastern Health Mental Health Services

Dr Mark Browne, Chief Psychiatrist

Senior Constable Jeremy Wilkinson, Nunawading Police Station.

Signature:

Apo

PARESA ANTONIADIS SPANOS CORONER Date: 21 August 2013

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