Mental health treatment provided to a Melbourne mother who killed herself and her three children was "suboptimal" and opportunities to intervene were missed.
Katica "Katie" Perinovic was being treated by doctors at North Western Mental Health after being diagnosed with first episode psychosis in November 2020.
Her husband Tomislav Perinovic arrived at their Tullamarine home after grocery shopping at lunchtime on January 14 2021 to find his three-year-old son Matthew in the kitchen with a stab wound.
He called an ambulance and while paramedics tried unsuccessfully to save his son he discovered the bodies of his daughter Claire, 7, and Anna, 5, in another room with Ms Perinovic's body.
All three had upper body wounds and a large kitchen knife was found nearby.
Coroner Audrey Jamieson found Ms Perinovic killed herself and her children during an episode of first episode psychosis.
Ms Perinovic was not complying properly with her medication regime.
The coroner couldn't say with any degree of certainty whether the deaths of the children were preventable but found treatment she received at North Western Mental Health was "suboptimal in the circumstances".
There was no causal link between Ms Perinovic's actions and treatment at NWMH or by her treating doctor, the coroner said.
"However, I find that there were missed opportunities to intervene in the course of events preceding and leading to (their deaths)," she said.
Family and friends had noticed a decline in Ms Perinovic's mental health in November 2020. She abruptly quit her physiotherapy job after 16 years, reportedly paranoid about work colleagues, the coroner said.
She had no prior history herself of mental illness, but was described as anxious, a worrier and at times impulsive.
She sought treatment from a GP and was referred to NWMH where she was diagnosed and prescribed medication.
Reviews over the phone and face-to-face in the days afterwards found she was still exhibiting paranoia but improving.
At a December appointment she told staff she thought she could stop taking the medication or reducing her dose and was told about the risk of relapse.
Ms Perinovic missed another review appointment on January 11, reporting that she had taken the children to the pool instead.
Three days later she and her children were dead.
The coroner noted restorative and preventative measures had been taken by the health service since 2021.
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