Inquest into the death of Dion White-Cotterell

Contributing factors

• Attacker's acute relapse of chronic schizophrenia
• Attacker's long history of violence when unwell
• Attacker's substance use (cannabis, amphetamines)
• Absence of comprehensive mental health care plan for attacker
• Lack of permanent consultant psychiatrist oversight at Parramatta CMH since June 2018
• Absence of documented formal multidisciplinary team reviews
• Limited engagement with attacker's family members despite them being listed as designated carers
• Community Treatment Order allowed to lapse in December 2018 without adequate risk assessment or documented clinical reasoning
• Inadequate quality of clinical documentation with copy-paste entries in Clozapine Clinic notes
• Failure of Homes NSW to escalate concerns to police or mental health services on 27 February 2019 when attacker presented with agitation and sweating
• Absence of memorandum of understanding between Homes NSW and WSLHD for information sharing

Coroner's recommendations

1. WSLHD to consider introducing a procedure requiring the development of a comprehensive care plan for patients being supervised or treated through its community mental health centres
2. Care plans to be reviewed and updated through multidisciplinary reviews that the community mental health centre is expected to carry out for patients
3. Care plans to ensure a section directed to key information about the patient's risk of violence when acutely unwell (including reference to key risk assessment reports if any exist) and mandate consideration of that in planning around frequency of contact and responding to a suspected relapse
4. Homes NSW and WSLHD to consider developing a memorandum of understanding as regards the exchange of information between Homes NSW and the WSLHD to facilitate community mental health services