Peter Jonathon Rex Bolton, 36

Peter, 36, had serious mental illness, an acquired brain injury and complex behavioural needs. His clinicians considered him ready to return to the community, but efforts to establish supported accommodation were unsuccessful, and NDIS applications for suitable support and accommodation were rejected. He spent more than ten months involuntarily detained in a locked psychiatric ward before dying by suicide.

This should not be described as an NDIS-caused death: the coroner found his hospital supervision, treatment and care were of a high standard. But the finding is powerful evidence of the consequences when disability and mental health systems are unable to agree, or provide a safe pathway out of hospital — the NDIS difficulties compounded an already extremely difficult discharge situation.