Within days of being discharged from a mental health facility, then-16-year-old Reginald Roy-Yunupingu became invisible to the systems designed to support him, the NT Coroners Court has heard.
Less than six months later, with no record of any remote mental health care, the teenager, who had suffered hallucinations, died in the remote Northern Territory community of Minyerri after climbing a power pole, touching a live wire and plummeting to the ground.
A two-day coronial inquest into "Reggie's" death heard the teenager was "lost to care" almost immediately after making strides towards recovery at Darwin's Youth Inpatient Program (YIP).
"This wasn't about falling through a crack in the system, this was the edge of a cliff which he fell off because there was no-one … to stop that happening," NT Coroner Elisabeth Armitage said.
The coroner heard Reginald's case was flagged with the Malak Re-engagement Centre, Headspace and Territory Families following his discharge from hospital.
But he was unable to attend Malak due to COVID-19, his Headspace file was closed upon advice Reginald would ultimately be returning to community and Territory Families "screened out" his case.
In closing submissions on Wednesday, counsel for the NT Health Department Tom Hutton acknowledged there was "uncertainty" around who was responsible for Reginald and his mental health care after his two-month stay as an inpatient.
"The issue at the centre of the inquest is why Reginald's trajectory for recovery did not continue once he left the YIP," said Mr Hutton.
"Regrettably Your Honour, that remains unclear."
The inquest heard Reginald was discharged to the care of family members who "almost immediately" struggled to care for him and called seeking assistance "almost every day".
"The Youth Inpatient Unit undertook to follow up with the communities, but there was no coordinated effort to do so," said counsel assisting Kelvin Currie.
Counsel for Territory Families, Maria Pikoulos, told the coroner the department conceded it should have investigated Reginald's case, after aunties reported there was no-one able to care for him in Darwin.
"The department accepts it should have taken greater action to facilitate Master Roy's transition back to community," Ms Pikoulos said.
Ms Armitage expressed frustration at the processes in place for families to access assistance from Territory Families, noting Reginald's family had contacted a social worker, who contacted the department, who then directed the family elsewhere for help.
"Why did the family have to seek [support] over and over again before it [was] delivered?" Ms Armitage queried.
"I understand the process but that's the frustration with the process which I think many families feel.
"It requires, after a family has already spoken to a social worker they're connected with [to say] 'I need help', you then put the responsibility back on the family to make a phone call to someone they don't know to say, 'I need help'.
Mr Currie urged the coroner to consider recommending the Territory Families Department make changes to its intake team procedures and include an avenue for case workers to undertake "further inquiries" upon welfare notifications.
He also suggested NT Health automatically refer patients who are from outside of Darwin to the Child and Adolescent Mental Health Service for "coordination, follow up and the provision of outpatient services".
Ms Armitage acknowledged that after two months as an inpatient "a lot had been invested" in Reginald's wellbeing, only for it to be lost within nine days of his discharge.
"[Health staff] were obviously invested in his wellbeing and wanted a good outcome for him," she said.
The coroner will hand down her findings and recommendations at a later date.
