CORONIAL LAW – diagnosis of mental health condition – psychotic depression / depression with psychotic features – care and treatment provided during admission at Nolan House including adequacy of risk assessments, observations, and treatment plans – method and nature of self-harm – impact of Nolan House being subject to both NSW and Victorian health oversight, policy, and guidelines – need for implementation of an electronic medical record across Albury Wodonga Health mental health services – need for induction process for locum and visiting staff members – need for implementation of improved risk assessment tools