Inquest into the Death of Laureen Kaye REILLY

[2024] WACOR 11 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER HEARD : 19 MARCH 2024 DELIVERED : 28 MARCH 2024 FILE NO/S : CORC 1107 of 2022

DECEASED : REILLY, LAUREEN KAYE Catchwords: Nil Legislation: Nil Counsel Appearing: Ms S Markham assisted the Coroner.

Ms R Hartley (SSO) appeared for the East Metropolitan Health Service.

Case(s) referred to in decision(s): Nil

[2024] WACOR 11 Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the death of Laureen Kaye REILLY with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, Perth, on 19 March 2024, find that the identity of the deceased person was Laureen Kaye REILLY and that death occurred on or about 3 May 2022 at BP Luxury Care, Unit 9, 22 The Crescent, Maddington, from combined drug toxicity in the following circumstances:

TABLE OF CONTENTS

[2024] WACOR 11 INTRODUCTION

1. At the time of her death, Laureen Reilly lived at BP Luxury Care Facility located in Maddington. Ms Reilly was found deceased in her room by facility staff on 3 May

2. A post mortem examination later established that Ms Reilly had died from combined drug toxicity, including heroin, cannabis and a number of prescription drugs.

3. Ms Reilly had a history of acquired brain injury, mental health disorders and substance abuse disorder. At the time of her death, Ms Reilly was being managed under a Community Treatment Order (CTO), which required her to receive fortnightly anti-psychotic injections. She was a patient of the Eudoria Street Clinic, where her depot injections were administered, and she received support and supervision at BP Luxury Care. Her last depot injection was due on the day she was found deceased.

4. By virtue of being on a CTO at the time of her death, Ms Reilly comes within the definition of a ‘person held in care’ under the Coroners Act 1996 (WA). In such circumstances, an inquest is mandatory and a coroner must consider her treatment, supervision and care.1 I held an inquest on 19 March 2024 in order to undertake that task.

5. The documentary evidence that comprised the coronial investigation into her death was tendered as evidence at the inquest. In addition, a number of witnesses were called to give evidence. I heard from Detective Sergeant Jennifer Binder in relation to the police investigation into Ms Reilly’s death, Ms Mahawa Bangura in relation to Ms Reilly’s management under the CTO at Eudoria Street Clinic and Mr Simon Vencatachellum and Dr Nalin Wijegunarathna in relation to the care and supervision provided to Ms Reilly at BP Luxury Care prior to her death, as well as the events leading up to the discovery of her body. Ms Reilly’s two sisters were also present at the inquest and provided some additional personal information.

6. At the conclusion of the inquest, I indicated that I was satisfied Ms Reilly received a high standard of treatment, supervision and care while on the CTO and that I would not be making any adverse comments in this matter.

BACKGROUND

6. Ms Reilly was born in Katanning and was raised by her parents with her three siblings. Ms Reilly was involved in a motor vehicle accident when she was five years old. She suffered a head injury and a permanent injury to her nose as a result of the accident and it seems she likely sustained a permanent brain injury that was diagnosed later in life. Ms Reilly spent her life up until the age of 14 years in various towns in regional Western Australia while her father worked as a station master.

Ms Reilly began to drink alcohol and get into some difficulties as she progressed to 1 Section 22(1)(a) Coroners Act.

[2024] WACOR 11 high school and she eventually left school at the age of 15 years of age. She worked as a roustabout and shearer’s mate for a time but never took up full time work.2

7. Ms Reilly was in various relationships, one of which resulted in Ms Reilly giving birth to a son. Her son was initially removed from her care after his birth, but then she was later able to regain care of her son and although he did not always live with her, she had continued contact with him thereafter. The father of Ms Reilly’s son died in 2005. Ms Reilly’s later relationships featured drug use and violence.

Ms Reilly had only sporadic contact with her family later in life due to her dysfunctional lifestyle and a propensity to violence.3

8. Ms Reilly began using illicit drugs from the age of 15 years and this led to conflict in her life and criminal behaviour. Ms Reilly had an extensive forensic history. She was incarcerated on several occasions, including receiving a three year prison sentence for stabbing a Department of Communities support worker while in conflict about her son being taken from her. She had also assaulted a hospital nurse, her mother and a former partner had been granted violence restraining orders against her.4

9. Ms Reilly suffered from mental health issues and her first admission to Graylands Hospital was in 1995. She was diagnosed with a personality disorder, psychotic disorder and polysubstance abuse, including heroin, cocaine, methyl-amphetamine, cannabis and benzodiazepines. Ms Reilly was case managed in the community through metropolitan and rural health services and over the years Ms Reilly engaged with services including Bunbury, Mirrabooka, Upper South West and Armadale. She was also involved with the START Court and received some mental health treatment while in custody.5

10. Ms Reilly had a number of involuntary in-patient admissions and had also been managed on a number of CTO’s in the community. She was noted often to be lost to follow-up in the community when there was no mandatory requirement to engage.6

11. Ms Reilly’s most recent psychiatric diagnosis was schizophrenia. She had also been diagnosed with an acquired brain injury with frontal lobe syndrome and cognitive impairment.7

12. Ms Reilly received a disability support pension. She had an appointed guardian and her finances were managed through the Public Trustee.8 2 Exhibit 1, Tab 6, Tab 12, Tab 17 and Tab 23.

3 Exhibit 1, Tab 6 and Tab 12.

4 Exhibit 1, Tab 17 and Tab 20.

5 Exhibit 1, Tab 12.

6 Exhibit 1, Tab 12.

7 Exhibit 1, Tab 12.

8 Exhibit 1, Tab 12.

[2024] WACOR 11 MENTAL HEALTH PRESENTATIONS IN 2021

13. On 24 March 2021, police attended the caravan park where Ms Reilly was living for an unrelated purpose. While there, park residents asked the police officers to check Ms Reilly’s cabin as they could smell gas. Police officers broke into her caravan and found Ms Reilly on the floor with the LPG stove gas running. Police officers called for an ambulance to attend.9

14. When SJA officers tried to assess Ms Reilly, she was resistant. She was eventually taken by ambulance to the Armadale Hospital Emergency Department for treatment.

At the hospital, Ms Reilly initially denied any suicidal ideation but agreed she had not been in a good state emotionally. She later admitted she had opened the gas tap with the intention of harming herself as she wanted to die. Her complex mental health history was noted and the fact she was not currently active with any services, having been discharged from a community treatment team in April 2020. The plan was to keep her in hospital overnight.10

15. It is not entirely clear from the records what happened in the following weeks. The records next show that Ms Reilly appeared in the Magistrates Court on 27 April 2021 for charges of alleged failure to obey orders given by an officers. She was noted to be unable to engage meaningfully in the Mental Health Court Liaison assessment due to her levels of distress and her acute psychotic illness. She could not give a coherent account of her charges and presented as acutely unwell. As a result, she was placed on a hospital order and transferred to the Frankland Centre for psychiatric treatment.11

16. Ms Reilly remained paranoid and thought disordered while in the Frankland Centre.

It was confirmed that she had not been compliant with her antipsychotic depot medication, Zuclopenthixol, since November 2020. Her Zuclopenthixol depot was recommenced on 29 April 2021. There were multiple Code Blacks called during this admission due to Ms Reilly’s level of aggression. She also reportedly attempted to strangle herself with her leggings. She remained in the Frankland Centre receiving treatment for 16 days until she was granted bail on 12 May 2021. Her bail conditions included that she comply with psychiatric treatment.12

17. Ms Reilly was transferred from the Frankland Centre on 12 May 2021 to Armadale Kelmscott District Memorial Hospital (Armadale Hospital). She was still very unwell at this time. Medical notes indicate Ms Reilly was floridly psychotic with marked hostility, aggression and agitation. She was frequently assessed as at risk to herself and others. She was verbally abusive towards staff and there was a constant concern she might physically assault them. Ms Reilly was administered medication in an attempt to decrease her agitation and reduce her level of risk, but it had limited effect. Regular periods of seclusion were required, as well as 1:1 nursing and security 9 Exhibit 1, Tab 17.

10 Exhibit 1, Tab 17.

11 Exhibit 1, Tab 12.

12 Exhibit 1, Tab 12.

[2024] WACOR 11 presence to keep Ms Reilly and those around her safe. Ms Reilly remained an involuntary patient in the locked ward throughout the entire admission.13

18. In mid-June 2021, Ms Reilly underwent a CT scan, which excluded an organic cause for her presentation. She then underwent electro-convulsive therapy, following which she demonstrated clinical improvement and remission from acute psychotic symptoms.14

19. Prior to this admission, Ms Reilly had been living in a caravan park and she had experienced previous periods of homelessness. Towards the end of her admission, the treating team were advised that Ms Reilly had been evicted from the caravan park. As she moved towards discharge, the hospital social worker and welfare officer began to work with Ms Reilly’s guardian and NDIS support worker to find alternative accommodation for her in the community.15

LAST COMMUNITY TREATMENT ORDER

20. After an inpatient admission of 113 days at Armadale Hospital, Ms Reilly was eventually discharged on 2 September 2021. She was placed on a CTO, so that she would continue to consistently receive her depot antipsychotic medication. She was placed at the BP Luxury Mental Health Care Facility in Maddington for a trial period with her follow-up mental health treatment to be provided by Eudoria Street Clinic at Armadale Community Mental Health Service. She was also linked in with the Carousel Medical Centre for her general medical treatment, and the doctors from the centre would visit BP Luxury Care once a fortnight.16

21. BP Luxury Care is managed by Roshana Care Group. It is a low care facility with 44 residents, all of whom have mental health diagnoses. They reside in 11 independent units, with each unit having two single rooms and one shared room, along with shared bathroom and common areas. Ms Reilly was allocated a single room in her unit. The residents generally go to the common dining area in the administration building for their meals, although they can prepare simple meals in their units. An activity planner records when residents attend their meals, their general appearance and presentation and if they are participating in activities. This assists in monitoring their mental health status. Medications are administered by staff at morning, lunch and dinner times and are recorded when administered.

Transportation is also provided for the residents to attend appointments when required 17

22. Ms Reilly’s Care Coordinator at Eudoria Street Clinic was Senior Social Worker Mahawa Bangura. Ms Reilly attended regular appointments at the Clinic with Ms Bangura and her psychiatrist Dr Chaitali Patel. She was assisted to attend 13 Exhibit 1, Tab 12 and Tab 14.

14 Exhibit 1, Tab 20.

15 Exhibit 1, Tab 20 and Tab 24.

16 Exhibit 1, Tab 12.2 and Tab 15.

17 Exhibit 1, Tab 24.

[2024] WACOR 11 appointments by staff from BP Luxury and her NDIS support worker from Ruah Community Services.

23. Ms Reilly initially received her depot injections at the Eudoria Street Clinic every two weeks and she was given the antipsychotic haloperidol.18 Ms Bangura gave evidence that Ms Reilly generally lacked insight into her mental illness and was resistant to receiving her depot medication. However, with encouragement and support, she was able to be given her depot medications as prescribed, although she was often quite hostile to staff during her appointments.19

24. At an appointment with Dr Patel and Ms Bangura on 1 October 2021, Ms Reilly indicated she was unhappy with her living arrangement and wanted to move to Busselton or Bunbury. She also indicated she did not want to receive her depot injections anymore. Dr Patel determined Ms Reilly needed to remain on a CTO and continue to receive her depot, but it was agreed she would be reviewed in four weeks. It was also arranged that Ms Bangura would liaise with her guardian about the possibility of being placed on the priority housing waitlist for Bunbury or Busselton. Ms Bangura recalled that following these discussions, Ms Reilly engaged better with her and she felt they established a small amount of rapport at this time.

25. When consulted, Ms Reilly’s guardian expressed a preference for Ms Reilly to remain living at BP Luxury while learning social skills. Therefore, she was not able to start making plans to move to independent living at that time.20

26. At her next psychiatric appointment on 1 November 2021, Ms Reilly was noticeably agitated and aggressive. She continued to express her wish to leave BP Luxury and live independently in Bunbury or Busselton. She also indicated she did not agree with her diagnosis and did not believe she required treatment. It was assessed that she had poor insight and judgment and inadequate capacity to make decisions for herself. The CTO and medical treatment was to continue but further consultation with her guardian about accommodation options was planned.21

27. On 4 November 2021, Ms Reilly received her last depot injection at the clinic. She was very reluctant to attend, so it was agreed she could begin to receive her depot injections at her GP service instead.22

28. To assist in assessing her ability to live independently, Ms Bangura arranged for Ms Reilly to have an occupational therapy assessment. Ms Reilly was assessed by an occupational therapist at the clinic on 15 November 2021 and it was determined that she needed ongoing and long term supports to improve and sustain independent living skills. Various supports that could be provided by NDIS were identified.

Ms Reilly reportedly agreed to move into supported independent living while awaiting a vacancy in the Busselton area and a plan was made for her case 18 Exhibit 1, Tab 12.

19 T 21 - 22.

20 Exhibit 1, Tab 12.

21 Exhibit 1, Tab 12.

22 Exhibit 1, Tab 12.

[2024] WACOR 11 coordinator to explore accommodation options with her guardian and NDIS provider.23

29. When Ms Reilly was reviewed again by her psychiatrist on 29 November 2021, she was irritable and frustrated that she had to continue to attend appointments. It was explained that the appointments were necessary under the terms of the CTO.24

30. Ms Reilly was offered assistance to attend her Mental Health Tribunal hearing on 10 December 2021 but she declined. The outcome of the hearing was that the CTO was to continue.

31. Ms Reilly was difficult to engage over the following months, although she continued to receive her depot medication. She eventually attended another clinic review with Dr Patel and Ms Bangura on 25 February 2022. She was irritable and dismissive about her mental health. She requested to be prescribed benzodiazepines and also to change her depot medication from haloperidol to zuclopenthixol, which she had been on in the past. Ms Reilly’s depot medication was changed, as requested, with the first dose administered that day in the clinic. She was also given a short course of a benzodiazepine. It was determined that her CTO should continue as there was a significant risk of non-adherence and non-engagement with mental health treatment if she was not on a CTO, which would negatively affect her mental health. Ms Reilly still expressed a wish to move to Busselton, so there were further discussions with her guardian after the appointment.

32. Ms Reilly’s most recent CTO form was completed on 25 February 2022, shortly after this last appointment with her psychiatrist. It confirmed a continuation of her CTO for a further three months, with an expiry date of 27 May 2022. Her antipsychotic medication was to continue as zuclopenthixol depot, and it was to be given at the clinic while she was transitioning onto the new medication. Ms Reilly received her next two depot injections at the clinic on 8 and 22 March 2022.25

33. A GP attended BP Luxury Care every two weeks to attend to the residents’ physical needs. Ms Reilly was last reviewed by her GP on 15 March 2022. She reported that she was feeling well and was not hearing any voices and did not feel paranoid. Her recent psychiatric review was noted and her medications were reviewed.

Examination of her chest and cardiovascular system were normal. It was noted that blood tests were to be performed the next month.26

34. Ms Reilly last saw her psychiatrist and care coordinator on 28 March 2022 at the clinic. She appeared relatively settled and less irritable than previously. She wished to restart Phenergan, which had been ceased at her request in February, as she was not sleeping without it. She reluctantly agreed to remain on her mood stabiliser lithium and her depot dose was increased. Ms Reilly was notified at this appointment that her treating doctor would be changing.

23 Exhibit 1, Tab 12 and Tab 22.

24 Exhibit 1, Tab 12.

25 Exhibit 1, Tab 12.1.

26 Exhibit 1, Tab 6 and Tab 15.

[2024] WACOR 11

35. Nursing staff attended at BP Luxury to give Ms Reilly her next injection on 20 April

2024. No concerns were noted on mental state examination.

36. Ms Reilly did not attend her scheduled face to face psychiatric review at the clinic on 26 April 2022 and the appointment was rescheduled for a month’s time. She was followed up by her care coordinator in the meantime, and BP Luxury staff brought her to the clinic on 29 April 2022. She saw her care coordinator, Ms Bungara, who recorded that she was relatively pleasant and engaged and her mood was reported to be fine. No formal thought disorder was identified and she denied any psychotic symptoms and any thoughts of self-harm. Ms Reilly again said that she wanted to move to Busselton, and Ms Bungara agreed she would complete another housing referral to try to get some progress with the request.

37. Ms Bungara gave evidence that the mental health treating team were aware of Ms Reilly’s history of illicit drug use, so she was regularly asked whether she was using drugs. She consistently denied any drug use and there was no other evidence to suggest that she was actively using drugs at this time. If she had admitted relapsing into drug use, Ms Bungara would have arranged for Ms Reilly to engage with drug and alcohol services.27

38. Evidence was given by Dr Nalin Wijegunarathna that Ms Reilly was discussed regularly at the monthly Roshana Care group meetings, as it was known that she was not engaging in the community activities and often left the facility, which made it hard to supervise her properly. Her wishes to live independently were acknowledged and the staff were willing to assist with that, but had to be guided by Ms Reilly’s guardian, NDIS provider and mental health care team. Ms Reilly was encouraged by staff to remain at the premises and participate in the care facility’s group activities, but it seems she was still absent from the facility regularly, most often immediately after she received her fortnightly pension and had some spending money available.

The facility staff were aware that Ms Reilly sometimes smoked cannabis, but they had no information to suggest she was using any other illicit drugs at this time.28

DISCOVERY OF MS REILLY’S BODY

39. Ms Reilly shared her unit with two other female residents.29 One of the residents spoke to police after Ms Reilly’s death and advised that Ms Reilly had a boyfriend named Simon. The resident mentioned that Simon had been to the unit at some stage and that there had possibly been an argument between Ms Reilly and Simon, but she couldn’t say when this occurred or provide any further detail.30

40. Progress notes provided by Roshana indicate a care worker had also seen Ms Reilly with a male person outside the unit on Saturday, 30 April 2022. She had told the worker that she was leaving to stay with her boyfriend. The care worker had advised Ms Reilly to speak with the manager first before making any decision about leaving.

27 T 24.

28 T 17.

29 Exhibit 1, Tab 10.

30 Exhibit 1, Tab 10.

[2024] WACOR 11 It seems she eventually decided not to leave on that night, as she was in her room the next morning to receive her medication.31

41. Attempts were later made by police to identify the person known as Simon. The police identified that Ms Reilly had been in a relationship with a man by the name of Simon in about 2010, but enquiries did not suggest this was the person Ms Reilly was seeing prior to her death, and no other person was identified.32

42. A support worker at the BP Luxury Care facility was on duty on the morning of Sunday, 1 May 2022. Normally, the residents would come to the dining area for breakfast and to receive their morning medications. If they did not, their medication would be taken to them in their rooms. On this morning, Ms Reilly did not come to the dining room for breakfast, so at about 8.15 am, the support worker took Ms Reilly’s medications to her. The support worker opened the unlocked front door to the unit where Ms Reilly’s room was located. The support worker then knocked on the door of Ms Reilly’s room. She answered, “Yes,” but did not immediately come to the door. The worker moved on to another resident’s room and gave them their medication, before returning to Ms Reilly’s room. Ms Reilly was now standing at the door. The support worker gave Ms Reilly her morning medications, which were 1 x lithium and 2 x paracetamol tablets and remained while she took the medications.

The support worker then left. That was the last time Ms Reilly is confirmed to be alive.33

43. According to the SJA patient care record, the same support worker tried to give Ms Reilly her night time medications that evening at her room at about 10.00 pm, but her room was locked and she did not answer her door. Other residents apparently said that she had gone out that afternoon and not returned.34

44. The Facility Manager at the time, Simon Vencatachellum, was on duty on the morning of Monday, 2 May 2022. During the shift handover, the night supervisor told Mr Vencatachellum that Ms Reilly had not returned to the facility on the Sunday night.35

45. Mr Vencatachellum went to Ms Reilly’s room at about 2.00 pm on the Monday afternoon, during part of his afternoon rounds. He knocked on her door, but Ms Reilly did not answer her door. He confirmed the bedroom door was locked, then went outside and looked through the room’s window. He could see Ms Reilly was not inside her room. There was also no sign of her in the common areas of the unit, including the bathroom. It is common for residents to come and go as they please at the facility. Ms Reilly, in particular, would often leave the facility during the day and she would sometimes stay out overnight if she had just been paid, so Mr Vencatachellum was not overly concerned.36 31 Exhibit 1, Tab 24.3.

32 T 9.

33 Exhibit 1, Tab 9.

34 Exhibit 1, Tab 7 and Tab 24.

35 Exhibit 1, Tab 8.

36 T 12, 18; Exhibit 1, Tab 8 and Tab 24.

[2024] WACOR 11

46. The next day, being Tuesday, 3 May 2022, Mr Vencatachellum was again on duty and he received an email from Ms Reilly’s community mental health care clinic advising that her anti-psychotic depot injection was due that day. Ms Bangura had sent the email at 10.00 am. She received a response back from Mr Vencatachellum advising that Ms Reilly had gone out to see friends and she had not been seen for two days. Ms Bangura advised that Ms Reilly should be brought to the clinic if she returned, or else the police should be informed that Ms Reilly was a missing person if she was not back by 2.00 pm that day.

47. Mr Vencatachellum contacted the Group Manager, Dr Wijegunarathna, and told him that they had not seen Ms Reilly for about 35 hours at the facility.

Dr Wijegunarathna agreed that the police would need to be notified that afternoon if Ms Reilly did not return.37

48. In the meantime, Mr Vencatachellum contacted Ms Reilly’s NDIS support worker in an attempt to find her. He was given Ms Reilly’s phone number, and he called it several times but it was switched off. He also spoke to the other residents, but non one had seen her. Mr Vencatachellum told the cleaner to go and check, and at around 2.00 pm, the facility cleaner advised Mr Vencatachellum that Ms Reilly’s door was still locked.38

49. Mr Vencatachellum did a further round checks that afternoon and went to Ms Reilly’s unit sometime between 3.00 pm and 4.00 pm. He checked that the door to Ms Reilly’s room was still locked and noted he could hear a television on inside.

He was certain the television had not been on when he had checked the room the previous day, which suggested to him that Ms Reilly had returned, although she was not answering her door.39

50. Mr Vencatachellum contacted Dr Wijegunarathna and requested permission to open Ms Reilly’s locked door. Permission was granted, so he went back to his office and collected a set of keys, which he then used to open the door to Ms Reilly’s room.

When he opened the door, Mr Vencatachellum immediately saw Ms Reilly lying on the floor of her room. Mr Vencatachellum checked her for a pulse and found none.

He saw no signs of life and believed Ms Reilly was deceased. Mr Vencatachellum asked another staff member to call emergency services and then closed Ms Reilly’s door so other residents would not be able to see her body, and remained with her until ambulance officers arrived.40

51. A support worker called St John Ambulance at 4.21 pm. The report was given that Ms Reilly was obviously deceased, as she was unresponsive, not breathing and appeared to be cold and stiff in a warm environment. An ambulance was despatched at 4.22 pm and they departed shortly after, arriving at the address in Maddington at 4.27 pm.41 37 Exhibit 1, Tab 8.

38 T 14 - 15; Exhibit 1, Tab 24.3.

39 T 15.

40 T 16; Exhibit 1, Tab 8 and Tab 24.3.

41 Exhibit 1, Tab 7.

[2024] WACOR 11

52. SJA officers were directed to Ms Reilly’s room at the facility. Upon entering the room, they observed Ms Reilly was lying on the floor in the right lateral position with her face covered by her hair. She had a small plastic bag underneath her left hand and there was a noticeable strong smell of cigarettes in the room. It was noted that when the SJA officers attempted to assess Ms Reilly, there was an electrical multi adaptor power board nearby, which caused interference with the ECG reading.

The SJA officers were required to turn the power off at the wall. They were then able to use the ECG to confirm that Ms Reilly was in asystole. An SJA paramedic also noted Ms Reilly showed signs of rigor mortis and was cold to the touch, with no audible breath sounds. An SJA paramedic certified Ms Reilly life extinct at 4.31 pm.42

53. WA Police had been contacted by SJA and advised of Ms Reilly’s death. Police officers quickly attended the scene and arrived shortly after the SJA officers. After Ms Reilly’s death was confirmed, the police officers commenced an investigation into Ms Reilly’s death. They did not find a syringe in the room, but it was possible the syringe had been removed by the SJA staff for safety reasons. They did find a wrapper for a syringe and seized the small clipseal bag that had been found in Ms Reilly’s hand, which was noted to be wet. Police officers also found a small bag of cannabis in a drawer, which was seized. Ms Reilly was formally identified by one of her carers43 and then the police arranged for Ms Reilly’s body to be conveyed to the State Mortuary for a post mortem examination as part of the investigation.44

CAUSE OF DEATH

54. At the request of Ms Reilly’s family, who objected to a full internal post mortem examination, an external only examination was conducted, with post mortem CT scanning performed. Forensic Pathologist Dr Ong conducted the examination.

Dr Ong noted that the CT scan showed patchy opacification of the lung fields. There was no significant injury observed.45

55. Toxicology analysis was undertaken, which demonstrated the presence of the opioid drug morphine within ranges seen in fatal cases involving heroin use. The heroin metabolite monoacetylmorphine was also detected in the blood, along with a small amount of codeine, which was most likely present as an impurity in the heroin.

Several prescription medications were also detected, including haloperidol, promethazine, clopenthixol and paracetamol. The presence of cannabis was detected, in addition to the other features suggestive of heroin use, but no alcohol or other common illicit drugs. Dr Ong observed that some of these medications possess sedating properties and, when taken in combination, may exhibit a synergistic (enhanced) effect, potentially resulting in increased sedation with a risk of loss of consciousness, coma and even death, particularly in the presence of high levels of morphine.46 42 Exhibit 1, Tab 2 and Tab 7 43 Exhibit 1, Tab 3.

44 T 8; Exhibit 1, Tab 6.

45 Exhibit 1, Tab 4.1.

46 Exhibit 1, Tab 5.1 and Tab 5.1.

[2024] WACOR 11

56. Dr Ong concluded that it appeared that Ms Reilly died as a result of combined drug toxicity.47 I accept and adopt the opinion of Dr Ong and find that the cause of Ms Reilly’s death was combined drug toxicity.

MANNER OF DEATH

57. Constable Christopher Abbott and Constable Amla Szalay from Gosnells Police Station were the first officers to attend the scene of Ms Reilly’s death on 3 May 2022.48

58. Upon arrival, the police officers observed the property was a mental health care facility. The police officers spoke to the staff and established that the last staff member who could confirm they saw Ms Reilly alive was Mr Chandrasekara, who had seen her on the morning of Sunday, 1 May 2022, when he gave Ms Reilly her medications at her room. The other residents have mental impairments and were not felt to be reliable witnesses.49

59. Documentation at the facility, including Ms Reilly’s medication chart and an activity planner, also confirmed Ms Reilly had not been recorded as seen by any staff from 1 May 2022.

60. Ms Reilly had been found lying on the floor with a power board underneath her. The room was generally untidy and messy but some money, bank cards and identification cards and her mobile phone were all found in the room, along with some paracetamol tablets. The presence of these items suggested that the room had not been disturbed by an intruder. The two police constables consulted with the WA Police Detective Crime Car to discuss if there was anything to suggest criminality in relation to the death. Following this discussion, it was concluded that there was no evidence to support criminality, third party involvement or suspicious circumstances surrounding Ms Reilly’s death.50

61. Police officers arranged for the clipseal bag found in Ms Reilly’s hand to be tested for drugs. The bag tested positive for acetylcodeine, codeine, diacetylmorphine (heroin) and monoacetylmorphine. The fact the bag was wet when Ms Reilly was discovered, suggested she had deliberately put liquid in the bag with the heroin, in order to inject it.51

62. At the conclusion of their investigation, including consideration of the forensic pathologist’s opinion on the cause of death, a coronial investigator from the Major Crime Division of the WA Police expressed the opinion that on the available evidence it appeared Ms Reilly had died as a result of an accidental drug overdose.

47 Exhibit 1, Tab 5.1 and Tab 5.1.

48 Exhibit 1, Tab 6 and Tab 7.

49 Exhibit 1, Tab 6 and Tab 10.

50 Exhibit 1, Tab 6.

51 T 7; Exhibit 2.

[2024] WACOR 11 The report was reviewed by Detective Sergeant Jennifer Binder from the Major Crime Division, who agreed with this conclusion.52

COMMENTS ON TREATMENT, SUPERVISION & CARE

63. Dr Wijegunarathna, as the Operational Manager for Mental Health & Recovery of Roshana Care Group, provided an overview of her care while at the BP Luxury facility. It was noted that Ms Reilly had last been seen alive on the morning of 1 May 2022, but it was a low care facility and her usual pattern was to go out frequently, so the staff were not immediately concerned.53

64. Ms Reilly was known to have a strong history of illicit drug use but during her stay at BP Luxury the staff had not found any evidence of drug use within the premises until the day she was found and she denied any drug use when questioned by her mental health team. She was given her prescription medications by staff, so she did not have access to them without supervision.54

65. Dr Wijegunarathna identified that there had been some concerns about Ms Reilly leaving the facility so often, and they had attempted to encourage her to stay at home more often, but this had not always been successful. The Activity Planner records show she had taken breakfast, lunch and dinner at the facility on Saturday, 30 April 2022 and was noted to have had a shower and changed her clothes and was generally engaging well with others, so there were no particular concerns about her mental state on that day.55

66. As noted above, Ms Reilly didn’t attend breakfast the next day, being Sunday, 1 May 2022, so her morning medications were taken to her in her unit by a support worker, who was the same person who had spoken to her the night before. That was the last time Ms Reilly received her medications. She was noted to be absent on the medication chart after that time and she did not present for any meals on 1, 2 or 3 May 2022. The general progress notes show that there were discussions on 2 and 3 May 2022 about Ms Reilly being missing, with various attempts made to locate her before she was discovered in her room during the afternoon of 3 May 2022. It is clear that the staff members’ concerns were escalating as the time went on, and taking appropriate steps to try to find her.

CONCLUSION

67. The evidence before me indicates that Ms Reilly returned to her room sometime after Mr Vencatachellum checked through the window of her room on 2 May 2022. It is probable she returned later in the morning of 3 May 2022, given she wasn’t present to receive her morning medications that day, although I can’t be certain of this. The evidence before me suggests Ms Reilly obtained some heroin while she was out and 52 Exhibit 1,Tab 6.

53 Exhibit 1, Tab 24.

54 T 27; Exhibit 1, Tab 24.

55 T 34; Exhibit 1, Tab 24.

[2024] WACOR 11 then injected the heroin at an unknown time on 3 May 2022, noting the drugs bag was still wet and the ambulance officers noticed a strong smell of cigarettes in the room when they arrived and rigor mortis was still present.

68. Ms Reilly died as a result of combined drug toxicity, noting that in addition to the heroin that was present, she also had a number of prescription medications, including her depot medication, and cannabis in her system. There is no evidence to suggest Ms Reilly had an intention to take her life when she took the heroin on a background of her regular medications. If, as the evidence suggests, she had not been using illicit drugs other than cannabis for some time, it is likely her tolerance to a drug like heroin would have been lower. In addition, as indicated by the forensic pathologist, the combined effects of the medications with the heroin, would be greater than the effect of any of the individual drugs. This combined effect was probably not considered or anticipated by Ms Reilly. Accordingly, I am satisfied that Ms Reilly death arose by way of accident.

69. I am satisfied that Ms Reilly received regular and consistent mental health treatment while on her CTO and that overall, her supervision, treatment and care was of a high standard. Sadly, her death appears to have arisen as a result of Ms Reilly’s relapse into illicit drug use.

S H Linton Deputy State Coroner 28 March 2024