A coroner has urged several changes be made by Albury Wodonga Health following the death of an involuntary mental health patient, with an inquest told the man should have been safe at the facility.
Subscribe now for unlimited access.
or signup to continue reading
Roger Schnelle died on April 30, 2021, two days after suffering self-inflicted injuries at Nolan House.
Mr Schnelle had been admitted to Nolan House on April 11 of that year after suffering a sudden mental deterioration.
Albury coroner Erin Kennedy on Thursday, May 16, said the sudden onset of mental health problems had been a shock to all who knew him.
"He had been a very successful, family orientated and very high functioning person, until very suddenly things changed," she said.
"His family took the steps of taking him to hospital to try and protect him.
"They put him in the safest place he could be, and yet he still could not be protected.
"It was important to explore how, while he was involuntarily detained and at high risk of harm, that he was still able to inflict injury sufficient to end his life.
"Roger's family wanted him kept safe, and he was not able to be kept safe.
"It must be accepted that from time to time even in these safe spaces people ... harm themselves."
Ms Kennedy found issues and missed opportunities with the care given to the 63-year-old, including a failure to identify a decline in his condition on April 23, a failure to escalate his care from April 24 and 25, and breakdowns in communication on April 26 and 27.
Albury Wodonga Health staff have made changes to an everyday structure unexpectedly used by Mr Schnelle to critically injure himself.
The late man's family suggested several other changes be made by the healthcare provider.
Ms Kennedy made four recommendations, including that the service advocate with health departments to implement electronic records with standardised documents for the assessment and management of patient risks.
The coroner also urged a review be undertaken into the way Albury Wodonga Health staff assess risk, patient observations and documentation, and that risk assessment tools focusing on risk management and risk indicators be implemented.
"I acknowledge the profound loss, continuing anguish, and heartbreak that Roger's family and friends are grappling with as a result of his very tragic passing," Ms Kennedy said.
"I offer my sincere and respectful condolences for their difficult loss."
Ms Kennedy ended her findings with the words shared by Mr Schnelle's partner, Yvonne.
"Roger's death deeply affected so many people," she said.
"Not just me, his children, his siblings but his broader family, friends and even acquaintances.
"Roger's support, knowledge and compassion was always available to anyone that needed it.
"He went out of his way to help and mentor his children, his brothers and sisters, his nieces and nephews, and his cousins.
"This extended beyond his family, to his friends and clients as well.
"He has had an enormous positive impact on the lives of so many."
Call Lifeline 24/7 for crisis support and suicide prevention services.
Help is available by calling 13 11 14. Text support is also available on 0477 13 11 14.
Call Beyond Blue 24/7 on 1300 22 4636 for advice, referral and support from a trained mental health professional.
