Paul Shen Vun Wong, 40

Paul, 40, had treatment-resistant schizophrenia. He had a community treatment order, a guardian, an NDIS support coordinator, and NDIS-funded daily supports. His sole support worker stopped attending, and provider Phoenix Community Care did not arrange a replacement or adequately alert his guardian, mental health team or support coordinator. Paul died alone from carbon monoxide toxicity, and may not have been discovered for up to 12 days.

This is one of the strongest NDIS accountability findings identified. The coroner expressly found that “the care network failed” and that Phoenix’s failures left Paul in “a position of extreme vulnerability”. Phoenix and its director were referred to the NDIS Quality and Safeguards Commission. The coroner recommended substantially greater transparency about provider registration conditions and adverse audit findings.