In any murder story, there is of course, the person who did it. Who is this person … David?

No attempt here is made to vilify the murderer, but rather to paint a background of why he did what he did. Now, David is a product of a difficult childhood that included various forms of abuse, neglect and addiction. He had been known to the mental health service from an early age and was relatively well managed. David was referred by LAMHIU to a government funded HASI (Housing and Support Initiative) program managed by On Track Community Programs and he was provided a unit in Lismore where he lived on his own with support from a team of mental health caseworkers.

David met Z (name not provided to protect her privacy) who herself was part of the Mental Health Refuge program at On Track Community Programs. The two individuals had entered into a relationship. In January 2009, David got an appointment with a local psychiatrist, Prof I. P. and convinced him to reduce the medications he was on as it was affecting his libido. It would appear that David got his wish as his medications were almost entirely withdrawn. In peer reviewed journal articles on medicating psychiatric patients, it is widely agreed that mood altering medication be slowly withdrawn and the patient monitored closely for adverse behavioural changes by the treating psychiatrist. This didn’t appear to be the case in this instance. The caseworkers at On Track Community Programs were not informed of the medication changes and only realised this when they were provided the scripts to collect the medications. An edited version made to the changes in medications are outlined in this report to the Health Care Complaints Commission.

The handwritten summary of critical events (given in the attachment to the right) reads in reverse chronology. Its originator is unknown but arrived together with other information sent by the CEO of On Track Community Programs. It shows David’s moods beginning to alter after the medication withdrawals in January 2009. For nearly 6 months, the On Track Community Programs Lismore branch Manager and David’s case manager from Richmond Clinic located at the Lismore Base Hospital get reports from his caseworkers (Michael and P) with concerns about David’s escalating level of aggression and violence. Yet, it does not appear that much is done to manage his escalating aggression. Were the pleas from the caseworkers ignored?

Should David have been in the community? On the Thursday before the murder, Michael and I had been driving around Lismore. We passed close to the unit where David was living and the topic of David’s release from an admission to Richmond Clinic came up. I asked the question “Should he even be in the community?” to which Michael responded, “I’ve already brought that up, but they ignored my concerns”. With Michael’s passing, I can now only guess at whom “they” referred to. It could be his immediate superior, the Lismore Manager; the Richmond Clinic Case Manager for David; or both.