17-year-old Reginald Gululpi Roy Yunupingu failed by NT mental health system

Coroner slams mental health protections for a young Territorian. “In my view this wasn’t about falling through a crack in the system, what he came to was the edge of a cliff.”

UPDATE, WED: NINE days was all it took for the Territory’s health and child protective services to lose a severely unwell teenager in their care.

Coroner Elisabeth Armitage said in little over a week Reginald Gululpi Roy aka Yunupingu was “completely lost” to the services meant to protect the vulnerable child just released from a Darwin mental health ward.

In the final day of the coronial inquest into the 17-year-old’s death, Ms Armitage said NT Health, Territory Families and mental health services effectively abandoned him and his family with no support.

“Within nine days of his discharge he was completely lost to any service providers,” Ms Armitage said on Wednesday.

“In my view this wasn’t about falling through a crack in the system, what he came to was the edge of a cliff.

“And that occurred in Darwin where all the services are located.”

The Ngukurr and Jilkminggan teenager, with a history of petrol and aerosol sniffing, was taken to Katherine Hospital by his family in January 2020 during a psychotic episode.

He was taken to Darwin’s Youth Inpatient unit where he described hallucinations of needing to “fight the devil” and being followed by “clever men … with long hair sitting cross legged”.

Over a 10-week stay the young teenager showed signs of improvement and prescribed antipsychotic monthly depot injections.

Ms Armitage said the planning and execution of the teenager’s release from the hospital was the start of a series of systemic failures.

The inquiry heard there was confusion and last minute changes to his discharge plan, largely due to Covid complications.

It was decided that 16-year-old Reginald would remain in Darwin, despite the wishes of his mother for him to return to community.

Reginald was sent to live with his grandmother and aunt in a Narrows apartment described as “overcrowded”.

“(His Aunt) almost immediately found it difficult to cope. She called seeking assistance almost every day,” Mr Currie said.

A report to Territory Families was “screened out” with no investigation despite the family saying no one in Darwin could care or control him and he was putting himself at risk.

The department’s legal representative said there were 13 earlier flags for Reginald dating back to when he was six-years-old, but in each instance his family had stepped in to help. She said this meant social workers did not believe it needed an investigation despite his family’s repeated concerns.

“Why did the family need to seek (help) over and over again before it’s delivered?” the coroner asked.

She voiced her “frustration”, saying what Territory Families described as “another avenue to empower families” was just “another hurdle” for vulnerable people.

“What did the Department do to assist and support the aunties?,” Ms Armitage asked.

“It was a referral to FACES (Families and Children Enquiry and Support),” the Territory Families representative said.

“Which did nothing,” Ms Armitage replied.

“In this particular context, it did nothing,” Territory Families admitted.

Ms Armitage said the system not only failed Reginald and his loved ones, but the medical teams who were “invested” in his wellbeing.

“I felt they were doing their best in an unclear scenario without the administrative support and the rest of it that would have helped them,” she said.

“The system let them down as well.”

Mr Currie said the vulnerable teenager was given a depot injection on April 9, and a week later Headspace closed his file.

The inquest was told the service believed Reginald was returning to community, where they had no outreach services.

“He was not seen or contacted by any other health staff after that,” Mr Currie said.

Six months later the teenage boy was found on a dirt road covered in electrical burns and raspily breathing for air.

His family said the mentally unwell child kept climbing structures, and on the morning of October 15 2020 he was electrocuted after touching a high-voltage power pole outside the Minyerri police station.

Mr Currie made submissions recommending changes in both Territory Families and NT Health.

He suggested Territory Families review procedures of “screening” cases and to implement a better workflow case management system to better track and coordinate the services needed for at-risk children.

Mr Currie submitted there should be an automatic referral of children from outside Darwin to Child and Adolescent Mental Health Services to coordinate follow up services.

The Territory Families representative also proposed submission to commit to information sharing across agencies “to enable robust decision making in relation to the safety and wellbeing of children”.

The final report with the formalised recommendations will be handed down at a later date.

INITIAL TUES: ON AN early October morning a 17-year old boy, haunted by visions of the devil, started a climb that would cost him his life.

Walking alone down a red dirt road Reginald Gululpi Roy aka Yunupingu approached the Minyerri police station and started to climb a nearby power pole on October 15 2020.

At the apex the 17-year-old touched a high-voltage wire, sending him plummeting to the ground. When he was found the teen’s breath was raspy and electrical burns marked body. The Health Clinic felt no pulse and he could not be revived.

Minyerri Community which is located 480kms southeast of Darwin, NT. Picture: Justin Kennedy

Seventeen months after the young Ngukurr and Jilkminggan teenager’s death, a two-day coronial inquiry is now investigating how the boy was left with no support, health referrals or follow up care after being a young involuntary mental health patient.

In his opening address on Tuesday counsel assisting the coroner, Kelvin Currie said the hearing would determine why more was not offered after the teen was flagged by Mental Health, the Volatile Substance Abuse team, Headspace, and Territory Families.

Reginald’s family, who sat in the front row of the packed courtroom, listened as government representatives apologised or explained the failures to protect their child.

The inquest heard Reginald may have started sniffing petrol at 13, and was experiencing visual and auditory hallucinations at 16.

His family took him to Katherine District Hospital in January 2020, and psychiatrist Nandini Das said the teenager was suffering from a psychotic episode triggered by cannabis use and a brain injury from chronic volatile substance use.

She said Reginald wanted to “fight the devil” and talked about “clever men … several men with long hair sitting cross legged and following him”.

Dr Das said Reginald’s condition improved significantly, and he was prescribed antipsychotic monthly depot injections. She noted the injections were an unusual treatment for a 16-year-old, saying in an urban setting “usually we try oral medication”.

“He did understand taking the medication was important for him … and we had the family on board,” she said

But Dr Das acknowledged Reginald’s discharge plan was not clearly discussed with his family, with last minute changes due to Covid causing significant disruptions to the mental health ward.

Coroner Elisabeth Armitage said Reginald’s mother asked for her son to return to Ngukurr, instead the Health Department released him to his grandmother’s two-bedroom home in the Narrows.

Elisabeth Armitage.

Within days his grandmother was calling for help, saying she was not prepared or given a discharge plan for her grandchild.

Mr Currie said his Aunties noted he was pacing around the house all night and left in the morning, with the pattern continuing over many sleepless nights. His family said Reginald liked to wander and climb structures particularly onto the roofs of houses.

The family continued to call over their concerns caring for and supervising the troubled teenager, contacting Territory Families on April 6.

One week after noting the teenager had ongoing “low grade psychotic symptoms” Headspace said they would be closing his file.

General Manager Top End Mental Health and Alcohol and Other Drugs Luke Butcher said this was the last contact between the mental health system and Reginald in the 184 days until his death.

Executive Director at Department for Child Protection and Family Support Julianne Davis said no action was taken because there was no evidence of “harm” — despite the legislation requiring action if no one could care for a child.

Mr Currie asked if it was wrong to screen him out for an investigation. “With the benefit of hindsight, yes,” Ms Davis said.

“The only difference between now and then is that he died … That’s not going to be a basis of decision making in Territory Families, is it?” Mr Currie pressed.

Ms Davis confirmed after Reginald’s death Territory Families undertook an internal review.

Darwin Local Court in the Darwin CBD Picture: Glenn Campbell

“There seems to be a dispute about who would follow up with referrals to community,” Mr Currie said.

Mr Butcher admitted there were “chronic issues” with the Territory’s mental health discharge system and said there was a patient management breakdown in Reginald’s case.

“He appears to be well loved by his family and extensive kinship network. He was a young man that undoubtedly had hopes, dreams and wishes for the life ahead of him.

“So on behalf of the service I would like to sincerely apologise to the family for any shortcomings in the … care given to Reginald.”

Family members have given permission to name the deceased.

The coronial inquest will continue on Wednesday.

Originally published as 17-year-old Reginald Gululpi Roy Yunupingu failed by NT mental health system