Walking alone down a red dirt road Reginald Gululpi Roy 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 plummeter 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 it could not be revived. 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. 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. “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 coronal inquest will continue on Wednesday.