Inquest into the death of Bryan G (aka) Abell Dallos

Contributing factors

• paranoid schizophrenia with fixed delusions regarding aircraft and flying to God
• treatment resistance and non-compliance with medication
• absconding from involuntary psychiatric detention without enforcement
• failure to return patient to psychiatric care despite involuntary detention order remaining in force
• inadequate coordination and communication between Mental Health Services and Northern Territory Police
• cessation of mental health monitoring after 19 September 2000 despite known ongoing risk
• unlocked aircraft in unsecured hangar
• lack of pilot experience or licence
• inadequate airport security measures
• patient had prior history of attempting to access aircraft at Darwin Airport

Coroner's recommendations

1. Senior officers of the Northern Territory Police meet with senior officials within Territory Health Services to create a joint protocol addressing: the nature of information exchanged between police and mental health services regarding absconding patients; the level within each organisation at which such information should be exchanged; the form of information exchange (telephone or formal minuted communication); who should be apprised of absconding and when; circumstances mandating expedient recovery plans; and whether the Mental Health Review Tribunal should be advised of absconding patients subject to tribunal orders
2. Creation of a formal template to be followed by both police and mental health professionals in the event of patient absconding, incorporating risk categorisation