Inquest into the death of Ashley Paull

Contributing factors

• Relapse of schizophrenia with associated psychotic symptoms
• Methamphetamine use and intoxication at toxic levels
• Non-compliance with depot antipsychotic medication due to medication gap
• Failure of mental health rapid response service to contact Ash despite Sandra's report of behavioural changes suggestive of psychosis
• Failure of mental health service to contact police regarding welfare concerns despite knowing Ash was at elevated risk of psychotic relapse
• Failure of police to access COPS information systems to identify Ash's schizophrenia diagnosis
• Failure of police custody manager to contact mental health services despite documented observations of mental illness and irrationality
• Release of visibly unwell individual from custody without mental health intervention or assessment
• Lack of communication and coordination between mental health services and police
• Inadequate documentation by mental health care coordinators of mental state assessments during home visits
• Use of police accompaniment for medication administration as routine intervention without exhausting less restrictive alternatives first
• Medication dose reduction without adequate monitoring in context of known poor compliance and substance use relapse

Coroner's recommendations

1. Consider amending the Charge Room and Custody Management SOPs, and/or the Police Handbook, to clarify the nature and extent of a review of information held on police systems that should be undertaken by arresting/escorting officers and custody managers where a person is in custody
2. Consider providing guidance to officers in charge of coronial investigations, where a person has died following a recent period in police custody, to ensure any CCTV footage depicting the person in custody is retained for the investigation