Inquest into the death of Paula Schubert

Contributing factors

• inadequate psychiatric note-keeping and documentation in electronic system
• failure to maintain communication with family, GP, and treating psychologist
• abrupt medication changes and transitions to GP care without proper planning
• inadequate crisis response and perceived abandonment by mental health service
• workplace bullying and inappropriate demotion process by employer
• failure of employer to accommodate mental health condition
• lack of support persons in workplace meetings
• public humiliation by manager in team meeting

Coroner's recommendations

1. Chief Executive Officer of Territory Families ensure managers and HR personnel are aware of their responsibility toward employees and refrain from bullying behaviour
2. Chief Executive Officer of Territory Families continue training of all managers and HR personnel to ensure sound understanding of appropriate supportive behaviours and accommodation of persons suffering impairment as defined in the Anti-Discrimination Act
3. Top End Health Service ensure that Mental Health Services keep proper patient notes and undertake all appropriate communication with stakeholders such as families, General Practitioners and other treating professionals