The heartbroken parents of a high-achieving but depressed 19-year-old Darwin woman who died last year say they were let down by a medical system that failed their daughter.
Sabrina Di Lembo's mother and father were speaking after the release of a coroner's report that was scathing about the care and treatment by medical professionals lacking "training or experience" and empathy.
Sabrina had won two scholarships and was achieving high marks studying law at university, but began suffering depression and daily panic attacks ahead of exams in May last year.
She took her own life two months later.
The coronial inquest in October into her death found that when Sabrina began to deteriorate, her worried mother phoned the Top End Mental Health Service who referred her to a GP, Kara Britz from Darwin's Tristar Clinic.
The parents Lidia and Michael Di Lembo were shocked to discover at the inquest Dr Britz was a registrar doctor and had failed examinations on at least five occasions to obtain the specialist general practitioner label.
The inquest found Dr Britz mistakenly prescribed half the minimum recommended dose of 75 milligrams of the anti-depressant Efexor and had failed to take notes.
Instead of being made "more relaxed and less anxious", Sabrina deteriorated, lost faith in the medication she was not taking enough of - and lost hope of recovering, Coroner Greg Cavanagh said.
Mr and Mrs Di Lembo this week said they were offended to discover Mental Health Service psychiatrist David Chapman had emailed a colleague "Tell mum to stop trying to be a doctor", after she had inquired about the medication not working.
Another doctor from the clinic, Bernard Westley, was dismissive of their requests for a psychiatrist.
"The lack of empathy by some of the professionals, that was just wrong," Mr Di Lembo told Mix radio.
"How can the Mental Health Service be a key provider and recommend someone that is probably not at the top of their game?," he said.
"It's just mind boggling."
The GPs and Mental Health Service had failed "in their duty of care" to Sabrina, Mrs Di Lembo said.
"If a proper assessment had been done from the outset then her path, her journey and our current situation may have been a very different story."
Mr and Mrs Di Lembo said there should be information publicly available with lists of GPs that have received ongoing training that qualifies them as having specialist knowledge about mental illness and treatment.
The coroner recommended the Top End Mental Health Service ensure all patients were properly assessed before referring them to GPs, and that the Medical Board of Australia remind GPs of their obligation to take a detailed history and a proper assessment of patients with mental health concerns.
NT Health Minister Natasha Fyles said she was taking the recommendations seriously, but Mr and Mrs Di Lembo said the coroner's office should be resourced to audit how its recommendations were implemented.
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