A coronial inquest has begun into the death of an 17-year old man who needed ongoing medical support but never got it as there was no record of him at his community clinic.
Kumanjayi Yunupingu died in the community of Minyerri about 240 kilometres southeast of Katherine in the Northern Territory in October 2020.
It was early in the morning when the teenager climbed up a power pole in front of the Minyerri Police station and was electrocuted.
The teenager had a history of serious mental health issues due to substance abuse.
In 2020, he was treated in a mental health facility in Darwin as an involuntary patient but was discharged after three months.
A number of separate government agencies were involved in his treatment and care - until he was released and allowed to return home.
"Why, in spite of, Mental Health, the Volatile Substance Abuse team, Headspace and Territory Families all being aware of his difficulties, there was no referral, support or follow up," said counsel assisting the coroner Kelvin Currie in his opening statement.
In April 2020 Mr Yunupingu's father took him home to the community of Ngukurr, but he moved to the nearby community of Menyerri to live with his Aunties.
The teenager should have received monthly injections at the community clinic as part of his treatment, that never happened.
"As it turned out there was no referral made to any health care provider for the ongoing care of Kumanjayi, including for the administration of his monthly injection," Mr Currie told the Inquest.
"There is no record of a referral or him attending the Health Clinic after his return to the community for any purpose."
The inquest in Darwin is set down for three days where members of the government agencies responsible for Mr Yunupingu's treatment and ongoing care are expected to be called to give evidence.
