Finding into death of Bayden Joel Quilkey

Contributing factors

• acute psychotic illness (likely paranoid schizophrenia)
• self-inflicted laceration injuries with blood loss
• agitated behaviour and physical resistance
• hot weather contributing to hyperthermia
• raised circulating catecholamines from agitation and restraint
• hypoxia from struggling and restraint
• lack of engagement with mental health services prior to crisis
• inadequate triage response and failure to mobilise home assessment

Coroner's recommendations

1. NorthWestern Mental Health should implement a policy, procedure or guideline for dealing with third-party referrers (family/carers) as quasi-customers or clients. The triage clinician should provide information about mental health symptoms, how to identify deterioration, and strategies to engage with the affected person when they are resistant to help. A clear action plan should be established for the referrer if the affected person's mental health deteriorates, including proactive follow-up contact within 18-24 hours.
2. Victoria Police should provide clarity to operational members and issue guidelines on the appropriate use of mobile phones whilst attending incidents. While acknowledging that private communication with supervising officers may sometimes be necessary, any decisions made during or on the basis of mobile phone calls should be communicated and transmitted over the radio so supervising officers remain fully informed.