Northern Territory health authorities failed to help a young Aboriginal petrol sniffer, who died after 14 years of addiction and despite ongoing pleas for treatment, a coroner has found.
Judge Greg Cavanagh has recommended an urgent review into health department procedures following the death of Edward Laurie, a violent and mentally-ill drug addict.
The 24-year-old had been sniffing since the age of 10 and was found dead in his home in the Aboriginal community of Bulla, 370 kilometres west of Katherine.
Judge Cavanagh said from 2008 until Mr Laurie's death in 2015, doctors, nurses and police lodged 16 rehabilitation applications.
"Seven of those were lodged in the last three weeks of his life," the judge said on Thursday.
He said the young man was "at risk of severe harm" yet the powers provided under the Volatile Substance Abuse Prevention Act for mandatory treatment orders were never used.
Mr Laurie, who suffered anorexia and drug-induced psychoses, fell into a predictable "downward spiral" with multiple stints in jail and hospital, Judge Cavanagh said.
At the age of 16 he spent more than a month in hospital after another sniffer threw petrol on him and set him alight, and he broke into houses and threatened people with knives in his search for fuel.
Less than a month before he died, police found Mr Laurie lying face down unconscious in a container of petrol, and he had previously been suffering seizures.
Mr Laurie had asked for help to quit but his family said he was too weak to undergo treatment voluntarily, and needed a mandatory court order.
About that time health department assessors considered closing Mr Laurie's case, claiming there was no rehabilitation centre in the NT that would take him due to his history of violence.
But Judge Cavanagh stressed that aggression is a symptom of withdrawal from volatile substances and sufferers shouldn't be denied treatment on that basis.
"Such people need assistance, perhaps more than those that are compliant," he said.
"If there was not a ready treatment option, the department needed to find or create one."
Over a 51-month period, assessors did not follow protocol and ignored their duties to recommend intervention programs to the Chief Health Officer, Judge Cavanagh said.
While they appeared to be "compassionate professionals", there was an obvious lack of leadership and supervision, he said.
The health department plans to undertake a comprehensive review into procedures which should finish in seven months.
"In the meantime there is an immediate need to ensure that appropriate training and supervision is provided to the staff to ensure that there is compliance with (the law)," Judge Cavanagh said.