Inquest into the death of Reginald Roy

Contributing factors

• Loss to mental health follow-up within 9 days of discharge
• Lack of coordinated care between inpatient and outpatient services
• Unclear responsibility between YIP and Headspace for outpatient care
• No single point of contact for family to report deterioration
• Discharge to unsuitable living arrangement without consultation with carer
• Family unprepared and unsupported to manage complex mental health needs
• Failure to provide monthly depot antipsychotic medication
• No engagement of Mental Health Assessment Team as advised
• Volatile Substance Abuse team closed case prematurely
• No follow-up by any service once patient returned to community
• Territory Families screening-out of referral despite multiple risk indicators

Coroner's recommendations

1. In cases where a young person from a remote community receives care in the Youth Inpatient Unit, there should be a referral to Child and Adolescent Mental Health to engage relevant and appropriate service providers (including primary care agencies) to establish care arrangements and support for young people and their families within community
2. Department Territory Families, Housing and Communities review the Central Intake Team Procedures and the Structured Decision Making Tool with a focus on incorporating the full section 20 considerations for when a child is in need of protection and deliver professional development for CIT Staff in relation to the revised practice
3. Department Territory Families, Housing and Communities include the 'Further Inquires' workflow/case type in the child protection response framework in the CARE case management system to be implemented in 2022
4. From 1 June 2022 there will be a single point of entry to the mental health service through the Mental Health Assessment Team's Mental Health Line
5. Discharge planning will start on admission and the admission policy will be revised to focus on planning for discharge, engagement of Allied Health, and engagement of Aboriginal Mental Health Workers
6. Each patient will have a 'journey board' to ensure a common understanding among staff as to the tasks that need to be completed during the patient's care, and to clearly articulate a focus on discharge planning
7. Patient dashboards will be established to prompt care escalation and secondary review for patients with extended stays in YIP
8. The Aboriginal Mental Health and Drug and Alcohol Community of Practice will be established to ensure the integration and collaborative care planning for Aboriginal patients
9. Patient medical records will be held in a central database, ACICIA, which will provide an integrated view of clinical information within a single login and report on overdue services and unattended appointments
10. Partnership arrangements, including with Headspace, will be reviewed to ensure arrangements support role delineation between agencies and provide support for stepped care approaches where patients are deteriorating
11. Clear identification of the person or entity responsible for a young person once discharged from inpatient care