Inquest into the death of Gwyyneth Cassiopeia-Roennfeldt

Contributing factors

• Rocky Manu not taking antipsychotic medication for 3.5 months prior to the incident
• No formal case manager appointed despite discharge plan specifying case management
• Failure of communication between inpatient and outpatient mental health services
• Absence of any system to monitor medication non-compliance or trigger clinical follow-up
• Rocky's paranoid delusions and persecutory ideation focused on flatmate
• Failure to escalate when warned about Rocky's deterioration on day of incident
• Inadequate risk assessment before approving co-tenancy arrangement
• Lack of leadership and management of Central Australian Mental Health Service (CAMHS)
• No safeguards for vulnerable co-tenant despite history of non-compliance and verbal aggression
• Failure to document or communicate case management plan to all relevant staff

Coroner's recommendations

1. That the role of Clinical Director of CAMHS be maintained, and that in the event of the current Director leaving the role, steps be put in place to ensure she is replaced as expeditiously as is feasible
2. That a quality assurance mechanism be set up to monitor implementation of the recommendations made in the Critical Incident Review reports commissioned following Jasmine's death
3. That the Office of the Northern Territory Coroner be advised of the quality assurance mechanism within three months of the date these findings are published
4. Implicit recommendations regarding: implementation of systems to track and escalate medication non-compliance; appointment of named case managers with clear responsibilities; regular review of joint tenancy arrangements with risk assessment; improved communication protocols between inpatient and outpatient services; maintenance of comprehensive case management plans