Finding into death of Philip John Roberts Hewitt

Contributing factors

• Failure to recognise explicit threat of homicide made by roommate on night of death
• Staff belief that threats were 'joking' despite 12-year documented history of similar threats
• Lack of mental health training for residential care staff
• Inadequate care plan for perpetrator that omitted reference to homicidal ideation despite documented history
• Placement of deceased with known dangerous individual without family consultation
• Lack of written policies for threat assessment and response
• Failure to escalate concerns to crisis assessment team or police when explicit threat was made
• Inadequate information gathering about perpetrator's history at admission to facility
• No separation of residents despite explicit threat being made

Coroner's recommendations

1. The Department of Health and Human Services should consider mandating mental health training for staff (or at least senior staff) in Supported Residential Services. The training should be sufficient to enable staff to recognise serious threats, interpret threats and take appropriate action.
2. The Department of Health and Human Services should incorporate in the Supported Residential Services compliance regime a requirement that proprietors ensure relevant staff undertake such mental health training.