Inquest into the death of Fiona Turnbull

Case Number: 2021/87981

Date of Findings: 6 March 2025

Magistrate: Deputy State Coroner, Elizabeth Ryan

CORONIAL LAW – death of a person from a fall from height – did mental health services respond appropriately – are there appropriate measures for information exchange between NSW Police Force and NSW Ambulance.

Responses

Recommendations

To the CEO of South Eastern Sydney Local Health District (SESLHD)

1. That the SESLHD review the instruction and training provided to clinicians of the Acute Care Team with regard to:

a) weighing the risks of possible police involvement when determining whether to request an immediate mental health assessment of a person reported to be acutely unwell; and

b) the manner of communicating with concerned persons to minimise the risk that they are mistakenly left with the view that responsibility for decision making about a response falls to the concerned persons.

To the Secretary of NSW Health

2. NSW Health in consultation with Local Health Districts, consider reviewing the arrangements for the provision of accreditation training in the case of Acute Care Team clinicians with a view to [significantly] increasing the number of clinicians with accreditation.