Coronial
NSWcommunity

Inquest into the death of Nicholas WATERLOW

Deceased

Nicholas Waterlow

Demographics

87y, male

Coroner

Decision ofDeputy State Coroner MacMahon

Date of death

2009-11-09

Finding date

2014-01-10

Cause of death

multiple stab wounds to the body inflicted by a known person

AI-generated summary

Nicholas Waterlow, aged 87, was killed by multiple stab wounds inflicted by a known person with untreated mental illness. The coroner found that ambiguities in the Mental Health Act 2007 may have hindered appropriate involuntary scheduling of the perpetrator, who had threatened the victim and exhibited signs of mental disorder. The case highlights the need for clearer legislative language regarding harm (including psychological harm to others) as grounds for mental health intervention. Clinicians involved in mental health assessment should understand that 'serious harm' in scheduling decisions should encompass emotional/psychological harm to others and harm from the mental illness itself, not just physical injury. Early recognition of risk through comprehensive assessment and engagement with community treatment orders may help prevent such tragedies.

AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatry

Error types

system

Contributing factors

  • untreated mental illness in perpetrator
  • ambiguities in Mental Health Act 2007 regarding scheduling criteria
  • unclear interpretation of 'serious harm' to include psychological/emotional harm
  • lack of clear guidance on protection of others from serious emotional harm

Coroner's recommendations

  1. Amend Mental Health Act 2007 section 14(1)(a) to expressly state that 'for the person's own protection from serious harm' includes harm caused by the mental illness itself
  2. Amend Mental Health Act 2007 section 14(1)(a) to expressly state that 'for the protection of others from serious harm' includes serious emotional harm
  3. Delete reference to physical harm in section 15(a) and (b) and specify that protection includes harm caused by mental illness itself and serious emotional harm to others
  4. Ensure no ambiguity in Part 1(1) of Schedule 1 regarding the test for scheduling patients
  5. NSW Health design and distribute an information booklet for families, carers and friends on supporting persons with mental illness/disorder who have been threatened by or are fearful of persons with possible mental illness
Full text

CORONER’S COURT Name of Deceased: Nicholas Waterlow File Number: 2009/473553 Hearing Dates: 18, 19, 21 & 22 February 2013 Location of Inquest: Coroners Court Glebe, NSW Date of Finding: 10 January 2014 Coroner: Magistrate P. A. MacMahon Deputy State Coroner Representations: Dr P Dwyer - Counsel Assisting.

Mr B Hull – St Vincent’s Hospital Mr J Morris – Dr P McGeorge Mr R Sergi – Nepean Blue Mountains Local Health District

Non-publication order made pursuant to Section 74(1)(b) Coroners Act 2009: Nil.

Findings made in accordance with Section 81(1) Coroners Act 2009: Nicholas Waterlow (born 30 August 1941) died on 9 November 2009 at 87 Clovelly Road Randwick in the State of New South Wales. The cause of his death was multiple stab wounds to the body inflicted on him by a known person.

Recommendations made in accordance with Section 82 (1) Coroners Act 2009: To the Minister for Health: That the NSW Government considers amending the Mental Health Act 2007 in order to:

  1. Expressly state that in determining whether to schedule a mentally ill patient pursuant to s.14 (1)(a), the term ‘for the person’s own protection from serious harm, should be understood to include the harm caused by the mental illness itself.

  2. Expressly state that in determining to schedule a mentally ill patient pursuant to s. 14(1)(a), the term for the protection of others from serious harm should be understood to include for the protection of others from serious emotional harm.

  3. Delete reference to physical harm in s. 15(a) and (b) and to specify that the term for the persons own protection from serious harm, should be taken to include the harm caused by the mental illness itself, and the term for the protection of others form serious harm should be understood to include for the protection of others from serious emotional harm.

  4. Ensure that there is no ambiguity in Part 1(1) of Schedule 1 as to the test that must be met before a patient is scheduled in accordance with the Act.

That NSW Health design and distribute an information booklet setting out advice (that includes an emphasis on the availability of community treatment orders) for families, carers and friends seeking to support persons suffering from a mental illness/disorder, who have been threatened by or are fearful of a person who may be suffering a mental illness/disorder.

Magistrate P A MacMahon Deputy State Coroner 10 January 2014

Source and disclaimer

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