Inquest into the death of Roger Frederick Schnelle

59y · Male·head injuries

Roger Schnelle, a 59-year-old accountant, died from head injuries sustained through intentional self-harm while involuntarily detained at Nolan House mental health facility in April 2021. He developed sudden onset severe mental illness (anxiety disorder with depressive features, with possible psychotic depression) triggered by debilitating vestibular symptoms. Despite rapid clinical deterioration from 21-28 April, risk assessment tools recorded him as "moderate" risk throughout. Critical failures included: inadequate escalation of nursing observations despite clear warning signs (threatening self-harm, attempted choking, concerning communications with family); lack of multidisciplinary risk formulation and management documentation; failure to communicate the banana self-harm attempt to treating team; and insufficient consideration of differential diagnosis of psychotic depression. The coroner found the risk assessment process was outdated and inadequate, observing levels should have been increased from 26 April onwards. While the specific method (sliding doors) was unforeseeable, systemic failures in risk communication and management reduced the patient's safety margins during a critical deterioration period.