A teenage boy who died in a remote Aboriginal community in 2020 "was not afforded basic mental health care" and was wrongly "screened out" by a government social services department, the Northern Territory Acting Coroner has found.
Reginald 'Reggie' Roy Yunupingu, 17, was known to enjoy climbing structures.
In October 2020, the teenager was found at the base of a power pole near the Minyerri Police Station, 240 kilometres south-east of Katherine, after climbing the pole, touching a wire and plummeting to the ground.
There was no suggestion his death was suicide.
Reginald had been released from a youth inpatient mental health facility in Darwin about six months before his death, where he was treated for psychosis and hallucinations.
But despite making strides towards recovery during the 10 weeks he spent as an inpatient at the Royal Darwin Hospital, Reginald was "lost to care" within nine days of his release.
"He did not receive his monthly depot medication in the six months that followed [his discharge].
"It appears there was no effective follow up of Reginald because there was no person or organisation that understood it to be their role to ensure continuity of his care."
His sister, who had been suffering from a similar condition, was also treated at the youth inpatient facility, and had also been discharged to family around the same time as Reginald.
The coronial inquest in March 2022 heard she had not been "lost to care".
Territory Families 'screened out' Reginald's case
Reginald was released from the youth inpatient facility to the care of family members, one of whom had not met with health staff prior to the discharge.
Ms Armitage found they quickly became overwhelmed with the responsibility, reaching out for help the day after his release.
Government department, Territory Families, was contacted around a week after Reginald's discharge and told there was "no safe persons in Darwin capable of caring for [Reginald and his sister]", as his father had his own mental health issues and his mother had not been his main carer for years.
However, despite it being the 13th notification in relation to Reginald, Territory Families "screened out" the case due to "insufficient information to suggest the children have been neglected or placed at risk of neglect."
"[Reginald and his sister] were children that may have been in need of care and protection … the combined history of referrals should have raised proper consideration as to whether or not Reginald had suffered from cumulative harm," Ms Armitage wrote.
Reginald's outpatient mental health care was initially the responsibility of Headspace, however when they were informed that he was going to leave Darwin for a remote community, his file was closed.
The coroner heard staff at the youth inpatient facility referred Reginald's case to the Katherine Mental Health Service and community clinics, despite the usual practise being for Headspace to make the referral.
Teenager's death a 'tragedy', coroner says
Reginald moved to Minyerri from Darwin with his mother sometime after June 2020 and the coroner found no evidence he engaged with mental health services there.
"There was a lack of clarity on the part of the family as to who had responsibility for Reginald's outpatient care," Ms Armitage wrote.
"Without a single point of call, there was a risk that the full picture of their concerns about Reginald's apparent deterioration and vulnerabilities could be missed."
The coroner ultimately recommended the Child and Adolescent Mental Health team be responsible for engaging relevant service providers in communities, for remote patients who are discharged from the youth inpatient unit.
She also recommended the Department of Territory Families, Housing and Communities review its intake procedures to broaden the range of issues it considers when deciding if a child needs protection.
The coroner heard Territory Families had since introduced some procedural changes since Reginald's death, and she recommended they also include a "Further Inquiries" case type and workflow in its case management system.
Ms Armitage noted Reginald had been "well cared for" during his stay at the youth inpatient unit and his death had "genuinely affected" the staff who cared for him.
She described his death as a "tragedy."
