Finding into death of Lewis John Muratori

Contributing factors

• Longstanding and worsening major depression
• Workplace bullying complaint and associated stress
• Suspension from nursing practice by regulatory board
• Loss of professional reputation and income uncertainty
• Loss of pet dog
• Financial stressors
• Highly distressing eight-hour compensation interview
• Perceived loss of employment
• Alcohol abuse
• Inadequate employer support and communication
• Failure of WorkSafe to escalate high-risk suicidal ideation information

Coroner's recommendations

1. Employers should be vigilant in performance reviews, document performance issues, and react accordingly; however, lack of documented performance issues may weaken assertions of performance problems raised after bullying complaints
2. Long-serving employees demonstrating out-of-character behaviour when mentally unwell deserve demonstrable support from employers
3. Employers should provide clear and timely formal notification to employees regarding employment status and matters affecting it, as a matter of procedural fairness and risk minimisation
4. Improved employer communication and contact with employees regarding their wellbeing
5. Time limits on compensation claim investigation interviews (WorkSafe subsequently implemented four-hour maximum)
6. Mandatory flagging and escalation of high-risk suicidal ideation in compensation claims
7. Enhanced training for claims managers in identifying and escalating high-risk claimants
8. Private investigators should receive ASIST training tailored to mental injury claims
9. Sensitive, compassionate handling of high-risk psychological injury claimants throughout claims process