Inquest into the Death of Paul Shen Vun WONG
Delivered on: 4 August 2026
Delivered at: Perth
Finding of: Brendyn Dean Nelson
Recommendations: Yes
Orders/Rules: No
Suppression Order: No
Recommendation No 1:
The National Disability and Safeguards Commissioner expand the information available on the register established under s 73ZDA of the National Disability Insurance Scheme Act 2013 (Cth) to enable members of the public to identify, at least:
- the total duration of a service provider’s registration;
- whether a provider’s registration is conditional; and
- if a provider’s registration is conditional, a summary of the substance of the conditions upon which the registration is approved (including whether the provider has been determined by audit to have any major non-conformities which are unaddressed).
Summary:
Paul Shen Vun Wong died at his home in Rockingham sometime on or after 13 April and by 25 April 2023. He was diagnosed with schizophrenia in 2001, after prodromal symptoms manifested in 1998. His mental illness was complex and treatment resistant.
At the date of his death, Paul was subject to a community treatment order, a guardianship and an administration order, and had a support coordinator and care support through NDIS funding. Despite this network, Paul died at his home alone from carbon monoxide toxicity from an unknown source and his death was not identified by anyone for, potentially, up to 12 days.
The Coroner found carbon monoxide toxicity to be the cause of Paul’s death. Although smoking, and smouldering cigarette butts within the property, appeared to be the only remaining putative source of the carbon monoxide, the Coroner determined that there was insufficient evidence to make such a finding. However, the Coroner excluded other verdicts and determined that the manner of death was accidental.
In commenting on the quality of supervision, care and treatment provided to Paul, the Coroner found that the care network failed. The Coroner found that the company contracted to provide day-to-day care supports to Paul (including monitoring of medication compliance), Phoenix Community Care (Phoenix), failed to find a replacement care worker when the sole carer who had been attending to Paul foreshadowed his resignation, or after he resigned. The Coroner also found that Phoenix and its director, Faisa Mohamud, failed to provide patently relevant information about the difficulties with providing a carer to Paul in March and April 2023 to any of his guardian, his community health team or his care coordinator. The Coroner found that Ms Mohamud’s lack of openness and honesty in response to direct queries left Paul in a position of extreme vulnerability and impeded the efforts of others in investigating their concerns for his welfare.
The Coroner determined that Phoenix and Ms Mohamud should be referred to the NDIS Quality and Safeguards Commission as the regulator of provision of disability support services.
Catch Words: Mandatory inquest - Community treatment order - Accident - Carbon monoxide toxicity.
Last updated: 13 August 2026