Inquest into the death of Fiona Turnbull
Deceased
Fiona Turnbull
Demographics
59y, female
Date of death
2017-10-12
Finding date
2025-03-06
Cause of death
multiple injuries from fall from height
AI-generated summary
Fiona Turnbull, a 59-year-old woman with chronic schizophrenia on clozapine, died from multiple injuries after falling from her third-floor balcony on 12 October 2017 during a psychotic relapse. The death occurred shortly after the unexpected death of her long-term partner and de facto father of her children. Critical clinical lessons include: (1) Mental health clinicians must ensure immediate assessments occur when patients present with acute psychotic symptoms and elevated harm risk, not deferring for convenience or family preferences about police involvement; (2) Communication with concerned family members must clarify that clinical decision-making responsibility rests with clinicians, not families; (3) Information sharing between NSW Police and Ambulance NSW about mental health history was inadequate—police possessed records of Fiona's psychiatric history but failed to communicate this when the ambulance was called; (4) More accredited mental health clinicians in after-hours Acute Care Teams would improve therapeutic options and reduce reliance on police for involuntary transport. The coroner determined that deferring assessment to the following morning was probably not material to the outcome, as an ACT team was unlikely to have been available that night regardless.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- acute relapse of schizophrenia with psychotic symptoms
- unexpected death of long-term partner two weeks prior
- delayed mental health assessment
- lack of accredited mental health clinician available after-hours
- family resistance to police involvement limiting assessment options
- failure to communicate clinical urgency to family members
- inadequate information sharing between NSW Police and NSW Ambulance regarding mental health history
Coroner's recommendations
- To the CEO, SESLHD: That the SESLHD review the instruction and training provided to clinicians of the Acute Care Team with regard to: (a) weighing the risks of possible police involvement when determining whether to request an immediate mental health assessment of a person reported to be acutely unwell; and (b) the manner of communicating with concerned persons to minimise the risk that they are mistakenly left with the view that responsibility for decision making about a response falls to the concerned persons.
- To the Chief Executive, NSW Health: That NSW Health, in consultation with Local Health Districts, consider reviewing the arrangements for the provision of accreditation training in the case of Acute Care Team clinicians with a view to significantly increasing the number of clinicians with accreditation.
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —