Deceased
Peter James Wilson
Demographics
41y, male
Coroner
Coroner Jenkin
Date of death
2021-11-01
Finding date
2024-06-26
Cause of death
complications in association with effects of fire, with terminal palliative care
AI-generated summary
Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 November 2021 after self-immolating with boat fuel while on a Community Treatment Order. Wilson was discharged from Graylands Hospital on 29 October 2021 following a 12-day admission for management of psychosis and recent suicidal behaviour (drain cleaner ingestion). Key deficiencies included: failure of discharging psychiatrist to discuss CTO directly with receiving community psychiatrist; non-provision of discharge summary to community service; absence of written information about diagnosis, new paliperidone depot injection, and potential medication side effects; and lack of weekend follow-up despite Friday discharge. While Wilson's mental state appeared stable at discharge and suicide risk was assessed as low, his parents later reported concerning medication side effects including tremors and breathing difficulty. The coroner found the discharge plan compromised but could not conclude that communication failures were causative of death, given the unpredictability of suicide and absence of documented acute warning signs.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
[2024] WACOR 27 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : MICHAEL ANDREW GLIDDON JENKIN HEARD : 21 - 22 MAY 2024 DELIVERED : 26 JUNE 2024 FILE NO/S : CORC 2901 of 2021
DECEASED : WILSON, PETER JAMES Catchwords: Nil Legislation: Coroners Act 1996 (WA) Mental Health Act 2014 (WA) Cases: Briginshaw v Briginshaw (1938) 60 CLR 336 Counsel Appearing: Ms S Markham appeared to assist the coroner.
Mr G Stockton and Mr J Kirke appeared for the North Metropolitan Health Service.
Mr S Taylor of counsel (21 May 2024) and Ms K Reynolds (Avant Law) (22 May 2024) appeared for Dr A Juniper and Dr J Hahn.
[2024] WACOR 27 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Michael Andrew Gliddon Jenkin, Coroner, having investigated the death of Peter James WILSON with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, PERTH, on 21 - 22 May 2024, find that the identity of the deceased person was Peter James WILSON and that death occurred on 1 November 2021 at Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, from complications in association with effects of fire, with terminal palliative care in the following circumstances: Table of Contents
Mr Peter James Wilson (Mr Wilson) died on 1 November 2021 at Fiona Stanley Hospital from the effects of fire, after dousing himself with boat fuel and setting himself alight. He was 41-years of age.1,2,3,4,5,6,7
At the time of his death, Mr Wilson was subject to a community treatment order (CTO)8 made under the Mental Health Act 2014 (WA) (MHA).9 Accordingly, immediately before his death he was an “involuntary patient” and thereby a “person held in care”. As a consequence, his death was a “reportable death” and in such circumstances, a coronial inquest is mandatory.10
Where, as here, the death is of a “person held in care”, I am required to comment on the quality of the supervision, treatment and care the person received while in that care.11 I held an inquest into Mr Wilson’s death on 21 - 22 May 2024, at which the following witnesses gave evidence: i. Dr Christopher Hodgson (Consultant Psychiatrist); ii. Dr Jayhee Hahn (Psychiatric Registrar); iii. Dr Liana Suparare (Consultant Psychiatrist); iv. Dr Asha Juniper, (Consultant Psychiatrist); v. Dr Mark Warrington (Psychiatric Registrar); vi. Dr Smitha Bhaduri (Director of Medical Services); vii. Mr Darren Schwartz (Acting Chief Pharmacist); and viii. Dr Adam Brett (Independent Consultant Psychiatrist).
The documentary evidence adduced at the inquest consisted of one volume and included reports from Mr Wilson’s treating psychiatrists, medical notes, and letters from Mr Wilson’s parents. The inquest focused on Mr Wilson’s supervision, treatment and care while he was the subject of a CTO, and the circumstances of his death.
1 Exhibit 1, Vol. 1, Tab 1, P100 - Report of Death (13.04.23) 2 Exhibit 1, Vol. 1, Tab 5, Death in Hospital form (01.01.22) 3 Exhibit 1, Vol. 1, Tab 6.1, P92 - Identification of Deceased Person (03.11.21) 4 Exhibit 1, Vol. 1, Tab 6.2, Affidavit - Sen. Const. S Dodge (03.01.22) 5 Exhibit 1, Vol. 1, Tab 6.3, Affidavit - Sen. Const. K Asher (03.01.22) 6 Exhibit 1, Vol. 1, Tab 6.4, Coronial Identification Report (03.01.22) 7 Exhibit 1, Vol. 1, Tab 7.1, Supplementary Post Mortem Report (04.01.22) 8 A CTO is an order under the MHA that requires a patient to submit to medical care and treatment in the community 9 Exhibit 1, Vol. 1, Tabs 16.1 & 16.2, Form 5A - Community Treatment Orders signed by Dr D Smith and Dr M Warrington 10 Section 21, Mental Health Act 2014 (WA) 11 Sections 3, 22(1)(a) & 25(3) Coroners Act 1996 (WA)
[2024] WACOR 27 MR WILSON Background12,13,14,15,16,17
Mr Wilson was born on 27 August 1980, and he was 41 years of age when he died. He finished school at Year 10 and had worked as a mechanical fitter for a number of years. Mr Wilson had two siblings, and although he married when he was 18 years of age, there were no children of the union, and he divorced his wife about two years later.
Although Mr Wilson had his own accommodation in Kingsley, he had been living with his mother who assisted him with the management of his mental health and supervised his medication. Although Mr Wilson had been working as a car detailer, he had recently given up working, reportedly as a result of workplace bullying.
Contact with mental health services: 2000 - 202018,19,20,21,22,23,24
Mr Wilson was admitted to the mental health unit at JHC and after treatment, he was discharged home on 1 May 2000.
12 Exhibit 1, Vol. 1, Tab 1, P100 - Report of Death (13.04.23) 13 Exhibit 1, Vol. 1, Tab 2, Report - Ms C Vernon Coronial Investigation Squad (26.04.23), p5 14 Exhibit 1, Vol. 1, Tab 24.1, Graylands Discharge Summary (18.09.21), p2 15 Exhibit 1, Vol. 1, Tab 17.1, SAC1 Investigation Report (13.02.22), pp3-4 16 Exhibit 1, Vol. 1, Tab 33, Report - Dr L Suparare (31.01.24), pp1-2 17 Exhibit 1, Vol. 1, Tabs 14.1 & 14.2, Background information and Family association list 18 Exhibit 1, Vol. 1, Tab 18, Report - Dr A Brett (17.10.23), pp2-6 19 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), pp1-2 and ts 21.05..24 (Hodgson), pp7-22 20 Exhibit 1, Vol. 1, Tab 31, Report - Dr M Warrington (19.01.24), p3 21 Exhibit 1, Vol. 1, Tab 34, Report - Dr D Smith (27.03.24), p1 22 Exhibit 1, Vol. 1, Tabs 26 & 28, Graylands Medical Records 23 Exhibit 1, Vol. 1, Tab 27, NMHS Medical Records 24 Exhibit 1, Vol. 1, Tab 25, Seacrest Medical Centre Medical Records
In 2016, Mr Wilson had several presentations to JHC in relation to drug induced psychosis. On 24 April 2016, Mr Wilson was admitted to the mental health unit at JHC under the provisions of the MHA, after his GP diagnosed him with drug-induced psychosis. Mr Wilson was taken to hospital by his mother, and he expressed paranoid delusions, including that he was being “chased by bikies”, and that “bikies were involved in the suicide death of his girlfriend”. He was treated as an involuntary patient on a locked ward, and prescribed the antidepressants aripiprazole and olanzapine.
Mr Wilson was discharged home as a voluntary patient on 16 May 2016, and referred to the Wanneroo Community Mental Health Service (the Service). His diagnoses on discharge were: “bipolar affective disorder?
A report of a clinical investigation after Mr Wilson’s death (SAC1) noted that insomnia featured heavily during Mr Wilson’s engagement with mental health services. It also appears that Mr Wilson’s medication compliance issues were related to his attempts to manage side effects and insomnia and that “Non-compliance with medication is a common cause of treatment failure and may have contributed to (Mr Wilson’s) ongoing symptoms”.25
The SAC1 also noted that it appeared that deteriorations in Mr Wilson’s mental health were preceded by his use of methylamphetamine, although he did manage long periods of abstinence. Although Mr Wilson was regularly offered referrals to drug rehabilitation services, he declined these referrals on each occasion.26,27 25 Exhibit 1, Vol. 1, Tab 17.1, SAC1 Investigation Report (13.02.22), p4 26 Exhibit 1, Vol. 1, Tab 17.1, SAC1 Investigation Report (13.02.22), p4 27 See also: ts 21.05.24 (Hodgson), p11; ts 21.05.24 (Hahn), p33; and ts 21.05.24 (Juniper), pp74-75
On 27 November 2019, Mr Wilson was reviewed by a consultant psychiatrist at the Service (Dr David Smith), following a referral from his GP. Dr Smith considered Mr Wilson had a mood disorder with psychotic features, and substance use disorder.28
Dr Smith noted that Mr Wilson had ceased using methylamphetamine, that his mood was “stable” and that Mr Wilson was “looking forward to a new job”. Dr Smith gave Mr Wilson strategies to maintain a normal mood in the presence of a mood disorder, including controlling substance use, maintaining a regular sleep/wake cycle, “developing psychological resilience”, and maintaining a healthy diet, regular exercise, and a daily routine. Dr Smith then discharged Mr Wilson back into the care of his GP.
Dr Smith says Mr Wilson subsequently ceased all of his medications “because he believed they were not helping him”, and Dr Smith saw Mr Wilson at the Service on 27 March 2020, with a “relapse of psychotic symptoms of auditory hallucinations of songs in his head”. Dr Smith saw Mr Wilson on several occasions and recommenced him on olanzapine, after an unsuccessful trial of lurasidone.
Dr Smith says that by 14 October 2020, Mr Wilson was “doing well” on a combination of paliperidone and olanzapine, and that Mr Wilson had said he did not want to go back on antidepressants. Mr Wilson’s obsessive compulsive disorder (OCD) symptoms were not of concern to him, and Mr Wilson said he did not want to engage in case management.
Dr Smith said that at no time in his care of Mr Wilson in the community “was suicidality or self-harm an issue” and when Mr Wilson was discharged from the Service into the care of his GP on 19 October 2020, his diagnoses were: mood disorder with psychotic episodes associated with substance use, and substance use disorder in remission.29,30,31 28 Exhibit 1, Vol. 1, Tab 34, Report - Dr D Smith (27.03.24), p1 29 Exhibit 1, Vol. 1, Tab 18, Report - Dr A Brett (17.10.23), p4 30 Exhibit 1, Vol. 1, Tab 34, Report - Dr D Smith (27.03.24), p1 31 See also: ts 21.05.24 (Hodgson), p19
[2024] WACOR 27 Contact with mental health services: 202132,33,34,35,36,37,38,39
On 27 June 2021, Mr Wilson was seen at JHC, and was diagnosed with depressive disorder, although he left before being reviewed by a psychiatrist. On 2 July 2021, Mr Wilson’s mother contacted the Service and reported concerns about her son’s mental health. An assessment was conducted, but on 11 July 2021, Mr Wilson was admitted to JHC after complaining of increasing anxiety, agitation, panic attacks, poor sleep, and worsening OCD behaviours.
Mr Wilson’s mental health had reportedly deteriorated after he had lost his job several weeks earlier. Although he was admitted to the mental health unit at JHC, Mr Wilson discharged himself against medical advice on 16 July 2021. Mr Wilson’s mother contacted the Service the following day to report that her son had “been discharged without medication and had decompensated”.
Mr Wilson was readmitted to JHC and complained of “bizarre movements and abnormal motor movements”, which settled when he was given intravenous midazolam. He reportedly made inconsistent statements about his polysubstance use, and a urine sample tested positive for methylamphetamine, cannabis, and benzodiazepines.
Mr Wilson was diagnosed with: “psychiatric, mental and behavioural disorders due to sedative or hypnotic dependence, anxiety, and OCD”, although there was no explanation for his presenting complaint.
Mr Wilson’s clinical impression was documented as: Atypical OCD symptoms, ?OCD. Likely GAD (Generalised Anxiety Disorder) along with Cluster C personality type (avoidant predominantly) with recent deterioration in the context of workplace bullying, with recent admission and considerable improvement since the addition of diazepam. Long-term insomnia likely secondary to anxiety.41
On 17 August 2021, Dr Hahn reviewed Mr Wilson at the Service. He described an increase in “OCD symptoms” including repetitive shaving, although an examination of his face did not reflect this. Mr Wilson also complained restlessness and unsteadiness, although Dr Hahn did not notice any signs of “agitation, tremor, abnormal facial or mouth movements, or restlessness”. Instead, Mr Wilson was seated calmly and engaging appropriately, and he was “mobilising independently with a “normal gait”.42
Dr Hahn noted that Mr Wilson “appeared to be focussed on Benzodiazepines to treat his problems”, but she explained that these medications have a high risk of addiction, and a plan to “wean him off them” was commenced. Dr Hahn noted that Mr Wilson had only started taking clomipramine three days earlier, despite it having been prescribed during his HiTH admission.43
Mr Wilson and his mother explained that “they did not want too many changes to his medications” and Dr Hahn clarified the medications Mr Wilson should be taking, and wrote this information on a piece of paper, which she handed to him. Mr Wilson denied any self-harm or suicidal ideation, and he engaged in a discussion on safety planning, which included ways to seek help if he needed it. Dr Hahn arranged a further review in four weeks, as neither Mr Wilson nor his mother wanted to see another doctor earlier.44 41 Exhibit 1, Vol. 1, Tab 18, Report - Dr A Brett (17.10.23), para 43, p6 42 Exhibit 1, Vol. 1, Tab 30, Report Dr J Hahn (29.11.23), p2 43 Exhibit 1, Vol. 1, Tab 30, Report Dr J Hahn (29.11.23), p2 44 Exhibit 1, Vol. 1, Tab 30, Report Dr J Hahn (29.11.23), p2
Dr Hahn’s impression and diagnosis was: generalised anxiety disorder, cluster C personality disorder with some depressive features (but not a clear depression), and OCD with reported symptoms including spending time in front of the mirror and excessive grooming.45
On 26 August 2021, Mr Wilson presented to JHC but he reportedly considered his physical complaints were dismissed, and staff allegedly told him “are you coming here again”. Mr Wilson was reportedly distressed by this comment, and he later said he contemplated suicide because he felt there was “no help for him” and he had “intense feelings of hopelessness”.46,47 Management at SCGH: 27 August 2021 - 7 September 202148,49,50,51,52
On 27 August 2021, Mr Wilson presented to JHC after ingesting drain cleaner (sodium hydroxide), and gave conflicting accounts as to why he had done so. After his physical injuries had been treated, Mr Wilson was subsequently admitted to Graylands Hospital (Graylands). In his report Dr Hodgson (who was Mr Wilson’s treating psychiatrist at Graylands) made the following observations about Mr Wilson’s ingestion of drain cleaner: Initially Mr Wilson reported that he wanted to end his life after experiencing a month of confusion, insomnia, his body moving oddly, and difficulty making decisions after licking the residue off his glass methylamphetamine pipe. Later in the admission he stated he had drunk the drain cleaner to alleviate his constipation reasoning that if it unblocked drains it might help to unblock his system. Given Mr Wilson’s grossly disordered behaviour and thinking at the time of the ingestion, his prior history of Psychosis, and his recent methyamphetamine use, I suspected that Mr Wilson was psychotic at the time of the caustic ingestion.53 45 Exhibit 1, Vol. 1, Tab 30, Report Dr J Hahn (29.11.23), p3 46 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), p2 and ts 21.05.24 (Hodgson), pp22-23 47 Exhibit 1, Vol. 1, Tab 33, Report - Dr L Suparare (31.01.24), p2 48 Exhibit 1, Vol. 1, Tab 18, Report - Dr A Brett (17.10.23), pp2 & 6-7 49 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), pp1-2 50 Exhibit 1, Vol. 1, Tab 24.2, SCGH Discharge Summary (07.09.21) 51 See also: Exhibit 1, Vol. 1, Tab 24.1, Graylands Discharge Summary (18.09.21), p1 52 Exhibit 1, Vol. 1, Tab 17.1, SAC1 Investigation Report (13.02.22), pp5-6 53 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), p2 and ts 21.05.24 (Hodgson), pp8-9
Mr Wilson was intubated due to swelling in his airway, and he was transferred to the intensive care unit at Sir Charles Gairdner Hospital (SCGH). A gastroscopy showed “erosion and slough in his oesophagus” but “no necrosis or perforation”. During this admission, Mr Wilson was also treated for aspiration pneumonia and encephalopathy, which he developed. Although Mr Wilson disclosed daily methylamphetamine use, he declined a referral to community rehabilitation services when he was assessed by the drug and alcohol team.
On 6 September 2021, Mr Wilson had recovered sufficiently to be reviewed by consultant psychiatrist, Dr Liana Suparare. Mr Wilson said that prior to ingesting the drain cleaner he had not been able to sleep or go to the toilet, and that “he should have admitted himself before his suicide attempt”. Mr Wilson’s obsessive thoughts about his appearance were noted, but he had “good insight about his condition and was willing to be admitted and treated.54,55
Mr Wilson was diagnosed with generalised anxiety disorder, body dysmorphic disorder, OCD, and cluster C personality disorder - dependent type with avoidant traits. Although he was assessed as not being at acute risk of self-harm, it was determined he required further assessments given his recent, serious, impulsive behaviour.
When reviewed by Dr Suparare on 7 September 2021, Mr Wilson identified workplace bullying as a “major stressor”, and he “expressed regret for his suicidal behaviour”. Mr Wilson denied any recent polysubstance use, and he also identified his family as “strong protective factors” in relation to his risk of self-harm. Dr Suparare considered that Mr Wilson required further psychiatric assessments, given the serious nature of his actions in ingesting drain cleaner, and negotiated his admission to Graylands as a voluntary patient.56,57,58 54 Exhibit 1, Vol. 1, Tab 18, Report - Dr A Brett (17.10.23), paras 48-49, pp6-7 55 Exhibit 1, Vol. 1, Tab 33, Report - Dr L Suparare (31.01.24), p2 and ts 21.05.24 (Suparare), pp35-36 56 Exhibit 1, Vol. 1, Tab 18, Report - Dr A Brett (17.10.23), para 51, p7 57 Exhibit 1, Vol. 1, Tab 24.2, SCGH Discharge Summary (07.09.21) 58 Exhibit 1, Vol. 1, Tab 33, Report - Dr L Suparare (31.01.24), pp2-3 and ts 21.05.24 (Suparare), pp38-43
[2024] WACOR 27 Admission to Graylands Hospital: 7 September 202159,60,61,62
Mr Wilson was transferred to Graylands as a voluntary patient on 7 September 2021. Because he lived in Banksia Hill, Mr Wilson would normally have been admitted to the mental health unit at JHC, but no beds were available, and in any case, Mr Wilson had previously indicated that he did not like being admitted to JHC.63
Mr Wilson was described as “pleasant and settled” on his arrival at Graylands, and he denied any self-harm or suicidal ideation. He disclosed a long-term history of polysubstance use (including methylamphetamine, alcohol, cannabis, and MDMA)64, and although he said he had last used methyamphetamine four weeks earlier, it was thought likely he was intoxicated when he ingested drain cleaner, as to which his discharge summary from Graylands observed: It is apparent that (Mr Wilson) was undergoing psychotic phenomena at the time of his caustic ingestion with superimposed likely delirium upon awakening in ICU. We do not believe (Mr Wilson) had suicidal or deliberate self-harm intent at the time of ingestion. We believe this was an attempt to alleviate constipation.65
Mr Wilson appeared settled on the ward and was cooperative with his treatment plan. He was diagnosed with “psychosis not otherwise specified”, and during his admission, the degree of his “thought disorder, beliefs of body dysmorphia and perception” improved and were “not evident at the time of discharge”. Mr Wilson was granted periods of leave with his family, and this culminated in weekend leave, following which he was described as “euthymic” (i.e.: normal, tranquil mental state/mood).66 Mr Wilson denied any suicidal ideation, and he was discharged into his mother’s care on 18 September 2021.
59 Exhibit 1, Vol. 1, Tab 18, Report - Dr A Brett (17.10.23), pp2 & 7-8 60 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), pp1-3 and ts 21.05..24 (Hodgson), pp7-22 61 Exhibit 1, Vol. 1, Tab 24.1, Graylands Discharge Summary (18.09.21) 62 Exhibit 1, Vol. 1, Tab 17.1, SAC1 Investigation Report (13.02.22), pp5-6 63 See for example: Exhibit 1, Vol. 1, Tab 24.2, SCGH Discharge Summary (07.09.21), p2 64 MDMA is the abbreviation for 3,4-Methylenedioxymethamphetamine, commonly known as Ecstasy 65 Exhibit 1, Vol. 1, Tab 24.1, Graylands Discharge Summary (18.09.21), p2 66 Exhibit 1, Vol. 1, Tab 24.1, Graylands Discharge Summary (18.09.21), p2
Following Mr Wilson’s discharge, ongoing support was to be provided by his GP and the Service. Mr Wilson’s discharge diagnoses were documented as: psychosis, obsessional personality disorder with OCD traits, Cluster C (avoidant) personality disorder, and generalised anxiety disorder.
Mr Wilson’s discharge medications included drugs to treat constipation (docusate, lactulose, Movicol, and senna), frusemide (a diuretic for oedema), pantoprazole (an antacid), and paracetamol for pain relief. He was also prescribed olanzapine and diazepam “as prophylaxis against psychosis and anxiety, and to aid sleep”.67,68
Dr Hahn reviewed Mr Wilson at the Service on 30 September 2021, with his interim case manager and his mother. Mr Wilson said his admission to Graylands had been helpful and he seemed brighter than at his previous review. In relation to drinking drain cleaner, Mr Wilson denied it had been a suicide attempt. He claimed he had been sitting on the toilet when he saw the drain cleaner, and had consumed it because he thought it would help with his constipation.69
Dr Hahn spent a significant portion of the review discussing Mr Wilson’s medications with him, and Mr Wilson denied any rumination or “fixations on his facial features”. He also said he had been keeping busy, and that his mental state was stable. Dr Hahn did not note any features of OCD, and Mr Wilson denied any symptoms of psychosis or self-harm ideation. Although Dr Hahn suggested a further review in two weeks, Mr Wilson’s mother requested an appointment in three weeks, so an appointment was scheduled for 22 October 2021.70
Dr Hahn also gave Mr Wilson instructions for his medications, and wrote a letter to his GP to update them on progress. Although Dr Hahn encouraged Mr Wilson to engage with drug rehabilitations services and see a psychologist, Mr Wilson declined, saying “did not feel he needed either at this time”.71 67 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), para 15, p3 68 Exhibit 1, Vol. 1, Tab 18, Report - Dr A Brett (17.10.23), para 56, p8 69 Exhibit 1, Vol. 1, Tab 30, Report Dr J Hahn (29.11.23), p3 70 Exhibit 1, Vol. 1, Tab 30, Report Dr J Hahn (29.11.23), p3 71 Exhibit 1, Vol. 1, Tab 30, Report Dr J Hahn (29.11.23), p3
[2024] WACOR 27 Psychiatric review - 14 October 202172,73,74,75
On 14 October 2021, Mr Wilson’s mother contacted the Service and requested an urgent review. She and her former husband had become very concerned about Mr Wilson’s welfare, and were unable to manage his level of risk at home. Although Dr Hahn was fully booked, she arranged to see Mr Wilson, and he attended the Service with both of his parents. Dr Hahn observed that Mr Wilson was “objectively low” compared to his previous with her, and she noted thought disorder, and apparent symptoms of psychosis. Mr Wilson also claimed his skin was “peeling off”, but Dr Hahn could not see this for herself.
Although Mr Wilson said he did not want to go to hospital, Dr Hahn was unconvinced that he would refrain from attempting suicide. Mr Wilson’s parents agreed that a hospital admission was needed. They also said they were not coping with Mr Wilson’s level of risk and felt the need to “monitor him constantly”. Mr Wilson was described as experiencing low mood, poor concentration, isolation, and psychomotor retardation and was expressing feelings of feelings of hopelessness/worthlessness.
In view of Mr Wilson’s perceived risk of self-harm, Dr Hahn determined that it was appropriate to place him on a Form 1A under the MHA (which required him to be taken to an authorised hospital and undergo a review by a psychiatrist). Mr Wilson’s parents did not want Mr Wilson admitted to JHC, “due to previous poor experiences there”, and so Dr Hahn arranged for Mr Wilson to be admitted to SCGH. Mr Wilson’s parents were able to transport him to SCGH immediately, and Dr Juniper (the clinical lead at the Service) subsequently agreed that Dr Hahn’s treatment plan was appropriate.
Dr Hahn called the psychiatric liaison nurse and a psychiatric registrar at SCGH to discuss her concerns about Mr Wilson’s presentation and to explain he was an “out of area” patient. A clinical nurse specialist from the Service also contacted the emergency department at SCGH to alert them to Mr Wilson’s imminent arrival.
72 Exhibit 1, Vol. 1, Tab 18, Report - Dr A Brett (17.10.23), p8 73 Exhibit 1, Vol. 1, Tab 30, Report Dr J Hahn (29.11.23), pp3-4 and ts 21.05.24 (Hahn), pp30-32 74 Exhibit 1, Vol. 1, Tab 31, Report - Dr M Warrington (19.01.24), p2 75 Exhibit 1, Vol. 1, Tab 17.1, SAC1 Investigation Report (13.02.22), pp5-6
Dr O’Sullivan also asserted that because Mr Wilson had been driven to SCGH by his parents, “he did not require the MHA as he had attended voluntarily”, and that in any case, a referral of this nature would require arrangement from the heads of service.76
Dr Juniper (who had been copied in to the email) responded to Dr O’Sullivan’s concerns, and Mr Wilson was admitted to the Mental Health Observation Area at SCGH. It was documented that Mr Wilson’s “long standing delusions of skin peeling (secondary to long-term amphetamine use) were “still present”, and he was diagnosed with possible schizophrenia and started on the antipsychotic, zucopenthixol.
The Form 1A which initiated Mr Wilson’s presentation at SCGH was revoked due to there being “no evidence of acute psychosis” and Mr Wilson not being suicidal “despite low mood”. Following his assessment at SCGH, Mr Wilson was transferred to Graylands on 15 October 2021, as a voluntary patient, and admitted under the care of Dr Smith.77,78 Transfer to Graylands Hospital: 15 October 202179,80,81,82,83
On his admission to Graylands, Mr Wilson was initially reviewed by Dr Suparare, who was “on call” at Graylands at the time. Dr Suparare noted that Mr Wilson had been discharged from Graylands on 18 September 2021, with a diagnosis of “psychosis” and that he had been followed up by the Service thereafter.84 76 Exhibit 1, Vol. 1, Tab 30, Report Dr J Hahn (29.11.23), p4 77 Exhibit 1, Vol. 1, Tab 30, Report Dr J Hahn (29.11.23), p4 78 Exhibit 1, Vol. 1, Tab 18, Report - Dr A Brett (17.10.23), p8 79 Exhibit 1, Vol. 1, Tab 18, Report - Dr A Brett (17.10.23), pp2-6 80 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), pp1-2 81 Exhibit 1, Vol. 1, Tab 28, Graylands Integrated Patient Records (16-29.10.21) 82 Exhibit 1, Vol. 1, Tab 31, Report - Dr M Warrington (19.01.24) and ts 21.05.24 (Warrington), pp49-72 83 Exhibit 1, Vol. 1, Tab 17.1, SAC1 Investigation Report (13.02.22), pp6-7 84 Exhibit 1, Vol. 1, Tab 33, Report - Dr L Suparare (31.01.24), p3
On assessment, Mr Wilson reported feeling depressed, and was experiencing “psychomotor retardation, had socially isolated himself, and was experiencing insomnia, poor concentration and feelings of hopelessness and worthlessness”. Dr Suparare noted that Mr Wilson was agreeable to an admission as a voluntary patient, and his care plan included routine observations, and a bowel chart and soft diet “as per the gastroenterologist’s recommendations”.85
When Mr Wilson was reviewed by the “duty consultant” on 16 October 2021, he was reported to be somewhat preoccupied with “somatic delusions about his skin peeling”, and constipation. He gave an unclear history of medication compliance and recent polysubstance use, and a urine screen was requested. Mr Wilson was placed on routine observations and given escorted grounds access.
Despite Mr Wilson’s complaints of insomnia, a sleep chart maintained during his admission found “almost all entries indicate the client was asleep at hourly checks”.86 Mr Wilson was given medication to treat his reported constipation, and he was regularly reviewed by medical staff.
Records indicate that Mr Wilson and his mother were involved in “assessments and care planning”, and in addition to Dr Smith, Mr Wilson’s treating team included Dr Mark Warrington, who was then a supervised medical officer in his first year.
Dr Warrington had a lengthy conversation with Mr Wilson’s mother about “Mr Wilson’s potential for primary psychotic illness”, and his medication regime. Dr Warrington also discussed Mr Wilson’s likely timeframe for admission, and indicated there would be further liaison with her, and likely a family meeting. During a multidisciplinary meeting later that day, Dr Smith confirmed he had previously treated Mr Wilson successfully in the community with paliperidone. A longlasting depot injection of paliperidone was planned due to uncertainty about Mr Wilson’s medication compliance, and Dr Smith expressed the view that Mr Wilson would benefit from being placed on a Community Treatment Order (CTO) under the MHA when he was discharged, to provide “assertive follow up” and to ensure compliance with medication.88 b. 19 October 2021: Mr Wilson was reviewed by Dr Warrington and started on a low oral dose of paliperidone, with a view to him receiving his “first depot loading dose” on 21 October 2021.
Mr Wilson was noted to be displaying some “abnormal lip smacking/jaw movements” that were suggestive of tardive dyskinesia, and his olanzapine dose was subsequently reduced.89 c. 20 October 2021: Dr Smith told Mr Wilson he believed that he (Mr Wilson) had a primary psychotic illness and that his mental health issues were not simply drug induced. Dr Smith also discussed the planned depot paliperidone injection, and that a CTO would be beneficial. Although Mr Wilson seemed “superficially agreeable to this plan”, he expressed concern about “potential side effects”.90 88 Exhibit 1, Vol. 1, Tab 31, Report - Dr M Warrington (19.01.24), pp4-5 and ts 21.05.24 (Warrington), p67 89 Exhibit 1, Vol. 1, Tab 31, Report - Dr M Warrington (19.01.24), p5 90 Exhibit 1, Vol. 1, Tab 31, Report - Dr M Warrington (19.01.24), p5
[2024] WACOR 27 d. 21 October 2021: Mr Wilson consented to receive his first depot loading dose of paliperidone, and Dr Warrington spent about 40 minutes with Mr Wilson’s mother discussing the treatment plan and the clinical impression which was being developed.
Dr Warrington arranged a family visit for the following day so that Mr Wilson’s care could be further discussed.91 e. 22 October 2021: a family meeting was conducted, attended initially by Mr Wilson’s treating team, and his mother, who expressed concerns about side effects from her son’s antipsychotic medication.
It was explained that Mr Wilson appeared to have a primary psychotic illness and that he would require ongoing treatment with antipsychotic medication. Dr Smith also noted that Mr Wilson had previously responded well to paliperidone.
Mr Wilson then joined the meeting and when he expressed concerns about possible side effects from his medication, Dr Smith highlighted the “ongoing psychotic phenomena Mr Wilson may experience” without treatment, and how this might lead to “further gestures where Mr Wilson may try to end his life again”. Ultimately it was agreed that Mr Wilson would receive a lower monthly dose of 75 mg of paliperidone, and the plan to discharge him on a CTO was discussed.
Mr Wilson was given day leave with his family over the weekend.92 f. 25 October 2021: Mr Wilson was reviewed by Dr Smith and Dr Warrington, and said day leave with his family had gone well.
Mr Wilson expressed “ongoing anxiety” about side effects from his depot medication, but other than a “mild fine tremor”, no obvious physical side effects were noted. Mr Wilson’s tardive dyskinesia symptoms were noted to be “improving”, and he was encouraged to engage in daytime ward activities rather than sleeping in order to “ameliorate his sleep/wake cycle”.93 g. 26 October 2021: when reviewed by Dr Smith, Mr Wilson expressed concern about weight gain caused by olanzapine, which was ceased in favour of quetiapine to help with sleep. Mr Wilson was again encouraged to engage in daytime ward activities.94 91 Exhibit 1, Vol. 1, Tab 31, Report - Dr M Warrington (19.01.24), p5 and ts 21.05.24 (Warrington), p67 92 Exhibit 1, Vol. 1, Tab 31, Report - Dr M Warrington (19.01.24), p6 and ts 21.05.24 (Warrington), pp66-67 93 Exhibit 1, Vol. 1, Tab 31, Report - Dr M Warrington (19.01.24), p6 94 Exhibit 1, Vol. 1, Tab 31, Report - Dr M Warrington (19.01.24), p6
[2024] WACOR 27 h. 27 October 2021: when Mr Wilson was reviewed by Dr Smith and Dr Warrington, and he appeared “more reactive and less blunted”. He disclosed he had not opened his bowels for five days, and was given some aperient medication prior to going out with his family for coffee.
Dr Warrington had a discussion with Mr Wilson’s mother about medication, and highlighted the importance of “reasonable control of psychotic symptoms to manage (Mr Wilson’s) risk and distress”. It was agreed that Mr Wilson’s reduced depot of paliperidone would go ahead the following day, and his mental state was assessed as “sufficiently stable to allow for registrar-led discharge”, which was planned for 29 October 2021.95 i. 28 October 2021: Mr Wilson consented to receive his second depotloading dose of paliperidone (i.e.: 75 mg).96 j. 29 October 2021: when reviewed by Dr Warrington prior to his discharge, Mr Wilson’s mental state was assessed as stable, and he continued to deny any suicidal or self-harm ideation. Mr Wilson was assessed as “reactive” and “generally pleasant to engage with”, and he did not demonstrate any signs of side effects.
Mr Wilson said he was looking forward to going home, and when Dr Warrington spoke with Mr Wilson’s mother, she “reported that she felt ready to take him home and thanked us for our care of him”.97
In his report, Dr Smith made the following observations about Mr Wilson’s presentation at the time of discharge: (Mr Wilson) was future focussed, in reasonable spirits, reasonably reactive and smiling on occasions. I interviewed him on several occasions including immediately prior to discharge and there was no indication of mental state changes that were of concern to me about self-harm or behaviours motivated by psychotic phenomena that might lead to harm as had occurred prior to the previous admission. If there had been such a concern I would not have discharged him from hospital. Because of my worry for his welfare, I placed (Mr Wilson) on a Community Treatment Order to increase the changes of his meaningful engagement with community services and to ensure he regularly received his depot medication.99 Transfer of Mr Wilson’s care to the Service100,101,102
As noted, when Mr Wilson was discharged, he was placed on a CTO by Dr Smith because of ongoing concerns about Mr Wilson’s risk of selfharm, and as a mechanism to ensure medication compliance. The CTO was confirmed by Dr Warrington, and although the plan was that Mr Wilson was to receive follow-up care in the community from the Service, there were issues with his transfer.
For a start, because Mr Wilson was an out of area patient, he had not been discussed during the weekly video conferences between Graylands clinicians, and its local community mental health service.103 This meant that the Service had no formal notification of Mr Wilson’s transfer into their care prior to his discharge.
At the inquest, Dr Hodgson explained that the usual practice for discharging an out of area patient from Graylands was that the treating clinician would telephone the relevant consultant psychiatrist at the patient’s receiving community mental health service to discuss the referral, and the patient’s on-going treatment and care.104 99 Exhibit 1, Vol. 1, Tab 34, Report - Dr D Smith (27.03.24), p2 100 Exhibit 1, Vol. 1, Tab 31, Report - Dr M Warrington (19.01.24), p7 and ts 21.05.24 (Warrington), pp62-64 & 70-72 101 Exhibit 1, Vol. 1, Tab 17.1, SAC1 Investigation Report (13.02.22), p7 102 Exhibit 1, Vol. 1, Tab 32, Report - Dr A Juniper (25.01.24), pp6-7 and ts 21.05.24 (Juniper), pp75-91 103 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), para 17.1, p3 104 ts 21.05.24 (Hodgson), pp16-21 and See also: ts 21.05.24 (Juniper), pp75-76
In Mr Wilson’s case, although Dr Smith called Dr Juniper (who was to be Mr Wilson’s treating psychiatrist at the Service) on 29 October 2021, she was unavailable as she was on leave that day. In her statement to the Court, Dr Juniper confirmed that Dr Smith telephoned the Service and says she was later told that Dr Smith advised an administrative officer that: The CTO had been discussed with me (Dr Juniper) and that I had accepted it, he (Dr Smith) also requested the appointment for (Mr Wilson) to see me, which (the administrative officer) scheduled for (Mr Wilson).105
In her report (and at the inquest), Dr Juniper confirmed that contrary to Dr Smith’s assertion, she did not discuss the CTO with him and that she “had not accepted the CTO, as I did not know about it”.106 In his report, Dr Smith says that when he called the Service, he was told that Dr Juniper “did not work Fridays” that “no alternative was made available”. Dr Smith also said he was aware that Dr Juniper had informally discussed Mr Wilson’s care with Dr Vanda Smith (who was the Head of Service at Graylands and also Dr Smith’s wife).107
Dr Smith says that during her conversation with Dr Vanda Smith, Dr Juniper had expressed “broad agreement with diagnosis and transfer on CTO”, and that both Mr Wilson and his family were “keen for discharge”. Mr Wilson had completed a successful period of leave the previous weekend, and Dr Smith explained his rationale for discharging Mr Wilson without speaking first with Dr Juniper in these terms: I was leaving the employment at the hospital that day. I did not want (Mr Wilson) to go through the process of getting to know another consultant, I did not perceive any acute risk issues, so I chose to discharge him. I could have put him on leave but that would have given the responsibility to the next consultant.108 105 Exhibit 1, Vol. 1, Tab 32, Report - Dr A Juniper (25.01.24), p7 and ts 21.05.24 (Juniper), p76 106 Exhibit 1, Vol. 1, Tab 32, Report - Dr A Juniper (25.01.24), p7 and ts 21.05.24 (Juniper), pp75-79 107 Exhibit 1, Vol. 1, Tab 34, Report - Dr D Smith (27.03.24), p2 108 Exhibit 1, Vol. 1, Tab 34, Report - Dr D Smith (27.03.24), p2
His parents are concerned with diagnosis and treatment but I assured them of its necessity. Sharon gave me an appointment for you to see him on 4 Nov at 1.30 pm. I will no longer be in the service when you get this and Mark Warrington the registrar can answer any queries.109
In his report, Dr Warrington confirmed the plan was that he was to make a follow up call to the Service on Monday, 1 November 2021, to discuss Mr Wilson’s referral to the Service on a CTO. Dr Warrington confirmed that “the CTO would be issued on the discharge date regardless”, and that he confirmed the CTO. Dr Warrington also said he had instructed the RMO to forward Mr Wilson’s discharge summary (which the RMO was responsible for drafting) to the Service, but that “this did not occur on this date”.110
As to her purported “broad agreement” to Mr Wilson’s diagnosis and his transfer to the Service on a CTO, at the inquest Dr Juniper conceded that she had spoken with Dr Vanda Smith about Mr Wilson at a “work function” on 28 October 2021. However, Dr Juniper denied this was a “formal discussion”, and also said that at that time: I hadn’t formally accepted the CTO, and I certainly didn’t feel I had enough information at that point to do so. I anticipated there would be further formal discussion with Dr David Smith.111 109 Exhibit 1, Vol. 1, Tab 26, Graylands Medical Records - Email Dr D Smith to Dr A Juniper (11.46 am, 29.10.21) 110 Exhibit 1, Vol. 1, Tab 31, Report - Dr M Warrington (19.01.24), p7 111 ts 21.05.24 (Juniper), pp78 & pp89-91
It is clearly unfortunate there was miscommunication about Mr Wilson’s discharge, and that Dr Smith was not able to speak with Dr Juniper (or another consultant psychiatrist at the Service), before Mr Wilson was discharged from Graylands.112 It is also unfortunate Mr Wilson’s discharge summary was not forwarded to the Service on 29 October
However, the question of whether any of these failures had any direct impact on Mr Wilson’s clinical journey is an entirely different matter.
The SAC1 concluded that although Mr Wilson was assessed as “low risk” when he was discharged from Graylands on 29 October 2021, “given that the discharge occurred on a Friday, the panel felt is was appropriate to alert and request follow up by after-hours/weekend (Service) staff of the client on discharge”.113
Further, in an email she sent to Dr Wojnarowska and others on 1 November 2021, Dr Juniper noted “the main concern here in relation to this man’s safety is around communication on discharge - for example perhaps weekend follow up from our afterhours team could have been helpful”.114,115 With the benefit considerable of hindsight, the views expressed by the SAC1 and Dr Juniper are clearly sensible.
However, at the inquest Dr Juniper agreed that even if Mr Wilson’s transfer to the Service been dealt with in the usual way, he would not have been reviewed by her until his appointment on 4 November 2021.
Whilst there was a possibility Mr Wilson may have been contacted by a mental health nurse on 1 November 2021, had the Service been aware of his referral on a CTO, that is as far as the evidence before me can go.116
112 ts 21.05.24 (Juniper), p91 113 Exhibit 1, Vol. 1, Tab 17.1, SAC1 Investigation Report (13.02.22), p10 114 Exhibit 1, Vol. 1, Tab 27, Email - Dr Juniper to Dr Wojnarowska and others (01.11.21) 115 ts 21.05.24 (Juniper), pp85-86 116 ts 21.05.24 (Juniper), pp78-79
In my view, the reason this is so significant is because both Mr Wilson and his mother had repeatedly expressed concerns about the potential side effects of his antipsychotic medication, and because Mr Wilson had only recently been started on a depot of paliperidone.
The SAC1 noted that it had been advised by the Pharmacy at Graylands that on discharge, the patient should be provided with written information on all new medication introduced during the admission.
Although this is usually done by the pharmacist, other staff (mainly medical), are also expected to provide information on any new medications.117
In a letter to the Court dated 6 June 2024, Mr Greg Stockton (counsel for NMHS) provided copies of information pamphlets relating to paliperidone, and noted that: The A/Chief Pharmacist, Mr Darren Schwartz, has advised that the usual practice of pharmacy staff at Graylands is to provide a copy of one of the drug specific information leaflets available on the Department of Health’s Choice and medication website118. Different leaflet formats and styles are available to match the reader’s health literacy level. Attached to this letter are three of the current leaflets available for paliperidone as a long-acting injection. Unfortunately, no record is available of what information was provided to Mr Wilson or his mother about paliperidone before Mr Wilson was discharged from Graylands Hospital on 29 October 2021.119 (Original emphasis)
The pamphlets attached to Mr Stockton’s letter contain a great deal of information about paliperidone depot injections, including an explanation of what paliperidone medication is and why it helps. The pamphlets also outline the likely timeframe for the medication to have an effect, and the possible side effects including the more common (e.g.: akathisia, movement disorders, pain at the injection site), and the less common (for which a doctor should be consulted, namely priapism, and neuroleptic malignant syndrome.120 117 Exhibit 1, Vol. 1, Tab 17.2, SAC1 Investigation Report Addendum (09.09.22), p3 118 See: https://www.choiceandmedication.org/wadoh/printable-leaflets/ 119 Exhibit 1, Vol. 1, Tabs 40.1-40.4, Letter - State Solicitors Office to Court & attachments e paliperidone (06.06.24) 120 See for example: Exhibit 1, Vol. 1, Tabs 40.2, Paliperidone palmitate monthly long-action injection
The other notable failure in relation to Mr Wilson’s discharge plan from Graylands was the fact that his discharge summary was not forwarded to the Service at the time he was discharged (i.e: 29 October 2021). The reason this was potentially significant was that if Mr Wilson had been seen by the Service’s after-hours team over the weekend after his discharge from Graylands, attending clinicians would not have had confirmation of Mr Wilson’s latest clinical summary, diagnosis, and medication regime.121
It appears to be standard procedure that one of the roles of junior doctors, such as RMOs, is the drafting of discharge summaries. In Mr Wilson’s case, although Dr Warrington had instructed the RMO to do so, the discharge summary was not forwarded in accordance with the procedure. At the inquest, Dr Warrington noted that that at the relevant time, he was responsible to two consultant psychiatrists, each of whom had a case load of seven patients.122
Thus Dr Warrington, and probably the RMO as well, each had 14 patients they were in some sense responsible for. In that context, the RMO’s failure to forward Mr Wilson’s discharge summary to the Service on 29 October 2021, whilst regrettable, is perhaps understandable.
EVENTS LEADING TO MR WILSON’S DEATH Observations 30 - 31 October 2021
During the weekend after Mr Wilson was discharged from Graylands, Mr Wilson’s mother says that her son was having trouble breathing and she was “forced to call a doctor”. She also says that “after a few days he (Mr Wilson) had such bad tremors that he could not do the simplest tasks”, and that these side effects “were never evident before”.123
According to Mr Wilson’s father, after Mr Wilson was discharged from Graylands, he seemed “very different” and was “quiet and withdrawn”.
121 ts 22.05.24 (Bhaduri), p101 122 ts 21.05.24 (Warrington), p49 123 Exhibit 1, Vol. 1, Tab 10, Statement - Ms A Wilson (02.11.21)
[2024] WACOR 27 Mr Wilson’s father also says that he and his ex-wife “attributed this to the new medication that he (Mr Wilson) was on”.124
However, I note that although Mr Wilson’s parents described him experiencing side effects after his release from Graylands, there is no evidence that either of them observed any signs that Mr Wilson was displaying behaviours which suggested he was at acute risk of suicide or self-harm.
It is well known that a person’s suicide risk can fluctuate wildly on a relatively short time frame, and that people who take their lives often show no signs or symptoms before doing so. In his report, Dr Hodgson referred to a comprehensive review of suicide research published in the American Psychological Association, in which the lead author (Professor Joseph Franklin of Harvard University) commented that: Our analysis showed that science could only predict future suicidal thoughts and behaviours about as well as random guessing. In other words, a suicide expert who conducted in-depth assessment of risk factors would predict a patient’s future suicidal thoughts and behaviours with the same degree of accuracy as someone with no knowledge of the patient who predicted based on a coin flip.125 Mr Wilson’s visit with father - 1 November 2021126,127,128,129
In a statement he gave on 2 November 2021, Mr Wilson’s father says that at about 10.30 am on 1 November 2021, he was at his home in Padbury, when his ex-wife (Mr Wilson’s mother), dropped Mr Wilson off for a visit. He and Mr Wilson went out and did some shopping, and on their return, he (Mr Wilson’s father) made them some lunch, and they watched a movie on TV.130
During the movie, Mr Wilson went outside for a cigarette, and his father followed him outside and asked if he wanted some music put on. When 124 Exhibit 1, Vol. 1, Tab 9, Statement - Mr S Wilson (02.11.21), paras 8-9 125 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), p6 and ts 21.05.24 (Hodgson), p22 126 Exhibit 1, Vol. 1, Tab 2, Report - Ms C Vernon Coronial Investigation Squad (26.04.23), pp2-4 127 Exhibit 1, Vol. 1, Tab 3, Memorandum - FC Const. S McGrady (01.11.21) 128 Exhibit 1, Vol. 1, Tab 4, Memorandum - Sen. Const. L Woolfe (02.11.21) 129 Exhibit 1, Vol. 1, Tab 12, WA Police Incident Report LWP21110100822579 (01.11.21) 130 Exhibit 1, Vol. 1, Tab 9, Statement - Mr S Wilson (02.11.21), paras 10-13
[2024] WACOR 27 Mr Wilson replied: “OK”, his father went inside and put on some music, before going to the back shed to fetch some weed spray.131
In a subsequent undated letter (which I read out at the inquest at his request), Mr Wilson’s father says after he made Mr Wilson some lunch, they went into the backyard and he tried to engage Mr Wilson in some gardening. However, Mr Wilson had “no coordination” and “even the simplest thing was an extreme effort” so instead, he wandered around the backyard having a cigarette. Mr Wilson’s father says he “sat (Mr Wilson) down at the patio table” before he went to the back shed for some spray.132
Either way, Mr Wilson’s father was only gone a matter of moments, and as he approached the tap at the back of his house he could hear a “roaring sound”. As he looked around the corner from the tap, Mr Wilson’s father saw to his horror that Mr Wilson was squatting in the garage, covered with flames. It appears that in the few moments he was alone, Mr Wilson went into the garage and doused himself with fuel from a jerry can labelled “boat fuel”, before setting himself alight.133,134,135,136
On seeing his son ablaze, Mr Wilson’s father rushed to the garage and used his coat to smother the flames engulfing Mr Wilson, before fetching a garden hose to do the same. Mr Wilson’s father’s actions in these appalling circumstances were incredibly brave, and he injured his hand after he placed it over the burning opening of the jerry can, which he feared was about to explode.137,138
As Mr Wilson’s father was calling emergency services, his ex-wife arrived, and they used the garden hose to cool Mr Wilson while they waited for an ambulance. A short time later police arrived and assisted 131 Exhibit 1, Vol. 1, Tab 9, Statement - Mr S Wilson (02.11.21), paras 14-17 132 Exhibit 1, Vol. 1, Tab 36.1, Letter - Mr S Wilson (undated) 133 Exhibit 1, Vol. 1, Tab 9, Statement - Mr S Wilson (02.11.21), paras 18-26 134 Exhibit 1, Vol. 1, Tab 36.1, Letter - Mr S Wilson (undated) 135 Exhibit 1, Vol. 1, Tab 11, Photographs of red jerry can labelled “boat fuel” 136 Exhibit 1, Vol. 1, Tab 2, Report - Ms C Vernon Coronial Investigation Squad (26.04.23), pp3-4 137 Exhibit 1, Vol. 1, Tab 9, Statement - Mr S Wilson (02.11.21), paras 21-23 138 Exhibit 1, Vol. 1, Tab 36.1, Letter - Mr S Wilson (undated)
[2024] WACOR 27 with first aid, before being joined by ambulance officers who took over Mr Wilson’s management and transported him to JHC.139,140,141,142,143 Transfer to hospital and management144,145,146,147,148,149
At JHC, Mr Wilson was assessed as having “full thickness burns” to 60 - 70% of his body. After his condition was stabilised, Mr Wilson was transferred to Fiona Stanley Hospital (FSH) by ambulance. At FSH Mr Wilson was taken to theatre and assessed by two burns consultants, who confirmed Mr Wilson had very severe burns involving about 60% of his body.
Mr Wilson was admitted to the intensive care unit where he underwent various specialist reviews. It was determined that Mr Wilson’s injuries were non-survivable, and following discussions with his family, it was decided to treat Mr Wilson palliatively. Mr Wilson was kept comfortable until he died at 6.58 pm on 1 November 2021.150,151,152
A forensic pathologist (Dr Ong), conducted an external post mortem examination of Mr Wilson’s body on 4 November 2021 and reviewed CT scans. Dr Ong also reviewed FSH medical notes, which confirmed Mr Wilson had sustained full thickness burns to 60% of his body.155
Dr Ong’s external examination noted “widespread thermal injuries the body surface and evidence of medical intervention”, whilst CT scans showed no evidence of significant skeletal injuries.156 139 Exhibit 1, Vol. 1, Tab 9, Statement - Mr S Wilson (02.11.21), paras 24-25 140 Exhibit 1, Vol. 1, Tab 36.1, Letter - Mr S Wilson (undated) 141 Exhibit 1, Vol. 1, Tabs 15.1, St John Ambulance Patient care records - Crew JOO42DD (02.11.21) 142 Exhibit 1, Vol. 1, Tabs 15.2, St John Ambulance Patient care record - Crew WAR22D2 (02.11.21) 143 Exhibit 1, Vol. 1, Tabs 15.3, St John Ambulance Patient care records - Crew CSN01D2 (02.11.21) 144 Exhibit 1, Vol. 1, Tab 23.1, JHC - Emergency Department Triage/Nursing Assessment (01.11.21) 145 Exhibit 1, Vol. 1, Tab 23.2, JHC - Emergency Department Trauma Record (01.11.21) 146 Exhibit 1, Vol. 1, Tab 22.1, FSH - Discharge Summary (01.11.21) 147 Exhibit 1, Vol. 1, Tab 22.2, FSH 0 Adult Triage Nursing Assessment (01.11.21) 148 Exhibit 1, Vol. 1, Tab 23.2, JHC Emergency Department Trauma Record (01.11.21) 149 Exhibit 1, Vol. 1, Tabs 15.1-15.3, St John Ambulance Patient care records (02.11.21) 150 Exhibit 1, Vol. 1, Tab 22.1, FSH - Discharge Summary (01.11.21) 151 Exhibit 1, Vol. 1, Tab 5, FSH - Death in Hospital Form (01.11.21) 152 Exhibit 1, Vol. 1, Tab 6, P92 - Identification of Deceased Person (03.11.21) 153 Exhibit 1, Vol. 1, Tab 7.1, Supplementary Post Mortem Report (04.01.22) 154 Exhibit 1, Vol. 1, Tab 7.2, Post Mortem Report (04.11.21) 155 Exhibit 1, Vol. 1, Tab 7.1, Supplementary Post Mortem Report (04.01.22) 156 Exhibit 1, Vol. 1, Tab 7.1, Supplementary Post Mortem Report (04.01.22)
Toxicological analysis found medications in Mr Wilson’s system that were consistent with his medical care. Alcohol and other common drugs were not detected.157
At the conclusion of his external post mortem examination, Dr Ong expressed the opinion that the cause of Mr Wilson’s death was “complications in association with effects of fire, with terminal palliative care”.158
I respectfully accept and adopt Dr Ong’s conclusion as my finding in relation to the cause of Mr Wilson’s death.
Further, in view of all of the circumstances, I find that Mr Wilson’s death occurred by way of suicide.
OTHER ISSUES RAISED BY THE EVIDENCE Side effects
The evidence establishes that Mr Wilson regularly complained of side effects which he attributed to his medication. These side effects included constipation, insomnia, tremors, odd body movements and weight gain. Mr Wilson’s mother also regularly raised concerns about the potential side effects of her son’s various medications.
At the inquest, Dr Hodgson (with whom Dr Warrington agreed) said that the true extent of Mr Wilson’s side effects was difficult to assess because Mr Wilson often reported side effects that were not observed by his treating clinicians. For example, Mr Wilson often reported insomnia, but during his last admission, a sleep chart recording hourly observations at night showed that he was almost always asleep.159,160
In his report, Dr Brett made the following comments about Mr Wilson’s side effects: 157 Exhibit 1, Vol. 1, Tab 8.1, Final Toxicology Report (24.12.21) 158 Exhibit 1, Vol. 1, Tab 7.1, Supplementary Post Mortem Report (04.01.22) 159 ts 21.05.24 (Hodgson), pp9-10 and ts 21.05.24 (Warrington), pp51, 56 & 69-70 160 See also: Exhibit 1, Vol. 1, Tab 30, Report Dr J Hahn (29.11.23), pp2 & 3 and ts 21.05.24 (Hahn), pp27-28
[2024] WACOR 27 There is good evidence that Mr Wilson was experiencing debilitating side effects from his medications following discharge. The description was consistent with akathisia. Mr Wilson had also experienced unusual neurological side effects (mild ataxia and dysdiadochokinesis) that would have benefitted from further investigation.161
Paliperidone163,164,165
In his report to the Court, the Acting Chief Pharmacist at Graylands (Mr Schwartz) explained that paliperidone is a second generation (or atypical) antipsychotic. This medication can be given orally or by way of long lasting depot injections. Mr Schwartz said that paliperidone is “indicated in the treatment of schizophrenia and bipolar disorder”, and its depot form, which is the most prescribed long acting injection in Western Australia, is used when medication compliance may be an issue.
Mr Schwartz noted that although the usual initial dose for a depot of paliperidone is 150 mg on “Day 0” followed by 100 mg on “Day 8”, Mr Wilson received 150 mg on 21 October 2021, followed by 75 mg on 28 October 2021. As I have explained, the reason for this lower second dose was that both Mr Wilson and his mother had expressed concerns about side effects, although as noted Mr Wilson had used this medication successfully in the past.
161 Exhibit 1, Vol. 1, Tab 18.1, Report - Dr A Brett (17.10.23), para 18, p14 and ts 21.05.24 (Brett), pp126-129 162 ts 22.05.24 (Schwartz), pp115-116 and see also: ts 21.05.24 (Juniper), p82 and ts 21.05.24 (Brett), pp125-126 163 Exhibit 1, Vol. 1, Tab 35, Report - Mr D Schwartz (07.05.24) and ts 22.05.24 (Schwartz), pp113-121 164 Exhibit 1, Vol. 1, Tab 17.2, SAC1 Investigation Report Addendum (09.09.22), pp2-4 165 See Also: and ts 21.05.24 (Warrington), pp69-70
As Mr Schwartz explained, antipsychotics can provoke extrapyramidal side effects (EPSE) such as tremor, dystonia (a movement disorder where muscles contract), and akathisia (an inability to sit still) in some patients by the dopamine blocking effects on dopamine receptors.
Mr Schwartz noted that Mr Wilson had been given several antipsychotic medications before the paliperidone depot and his dose of diazepam had been progressively reduced before being ceased. However, Dr Schwartz also noted that although paliperidone does carry the risk of EPSE including akathisia: [I]t is rare for akathisia to set in immediately after the initiation of a depot (long acting injection) simply because the initial release and build-up of antipsychotic levels takes much longer when a long acting injection is used. Akathisia is far more common with oral medication than with depot medication.166
In an addendum to the SAC1, which was published following a family meeting with Mr Wilson’s parents in June 2022, the panel noted: Pharmacy further advised that although rare, akathisia can be induced shortly after a paliperidone depot injection is administered. This side effect is not common with depot antipsychotics as it would be with short acting ones. Pharmacy advised it is less likely that (Mr Wilson) suffered side effects from paliperidone that from the total amount of medications given during the admission, however, it is unlikely side effects from the medications would have caused (Mr Wilson) to selfimmolate.167
In the addendum, the panel also noted that Mr Wilson had a history of dystonic reactions to typical and atypical antipsychotic medications and had experienced EPSE. In this case, Mr Wilson had successfully used paliperidone in the past, and at the inquest, Dr Brett said that patients are often started on antipsychotic depot injections in the community.168 166 Exhibit 1, Vol. 1, Tab 35, Report - Mr D Schwartz (07.05.24) and ts 22.05.24 (Schwartz), pp117-119 167 Exhibit 1, Vol. 1, Tab 17.2, SAC1 Investigation Report Addendum (09.09.22), p3 168 ts 21.05.24 (Brett), p145
Mr Wilson received his first two depot doses of paliperidone at Graylands, although the second dose was given the day before his discharge. When reviewed by Dr Warrington on 29 October 2021 prior to his discharge, Mr Wilson’s mental state was stable and he denied any suicidal ideation. Dr Warrington also said Mr Wilson “did not demonstrate any side effects from his medication during this review”.169
Mr Schwartz reviewed a letter from Mr Wilson’s mother and spoke to one of the consultants on the SAC1 panel, before observing: [I]t seems likely that Mr Wilson was suffering from significant side effects from the medications used. Having said that, Dr Brett points out the lack of research in the area associating akathisia (or other EPSE) with suicide. Although medication side effects could contribute to the impetus to make a suicide attempt, I would be reluctant to attribute a single cause such as medication side effects as the sole prompt for a suicide attempt.170,171 Cessation of diazepam
Diazepam is a benzodiazepine medication that can be useful in controlling some side effects of antipsychotic medications, including reducing the effects of akathisia. However, long-term use of diazepam can be problematic due to issues of dependence, and the risk of unwanted side effects including cognitive impairment, memory problems and mood swings.
Mr Wilson’s diazepam dose was gradually reduced during his last admission at Graylands so that by the time he was discharged it had been completely withdrawn. At the inquest, Dr Hodgson and Mr Schwartz both said that the cessation of Mr Wilson’s diazepam was managed appropriately. Further, despite Ms Wilson’s firm views to the contrary, there is no evidence before me that the cessation of Mr Wilson’s diazepam had anything to do with his death.172,173 169 Exhibit 1, Vol. 1, Tab 31, Report - Dr M Warrington (19.01.24), p7 170 Exhibit 1, Vol. 1, Tab 35, Report - Mr D Schwartz (07.05.24), pp3-4 and ts 22.05.24 (Schwartz), pp119-120 171 ts 22.05.24 (Brett), p140 172 ts 2x.05.24 (Hodgson), p10; ts 21.05.24 (Schwartz), pp114 & 117; and see also: ts 22.05.24 (Brett), p129 173 Exhibit 1, Vol. 1, Tab 10, Statement - Ms A Wilson (02.11.21)
[2024] WACOR 27 Transfer of patients on CTO
As I have outlined, Mr Wilson’s discharge from Graylands on 29 October 2021 was marred by miscommunication between Graylands and the Service, and by the failure to provide Mr Wilson and his mother with relevant information about his diagnosis and his new medication regime.
The information which clearly should have been provided to Mr Wilson and his mother should also have included the potential side effects of Mr Wilson’s medication (including paliperidone) and the signs to look out for which would indicate that Mr Wilson’s mental was deteriorating.
There should also have been an indication of the pathway back into care if Mr Wilson’s mental state was noted to be deteriorating.
QUALITY OF SUPERVISION, TREATMENT AND CARE SAC1 findings176
The SAC1 noted that Mr Wilson’s mental state had “deteriorated significantly” in the four or five months prior to his death. Although Mr Wilson had reportedly stopped using illicit substances and received treatment from mental health professionals during this period, he continued to complain of issues with insomnia and constipation, and he appeared to develop symptoms of a depressive disorder and psychosis.
The SAC1 expressed the following conclusions about Mr Wilson’s treatment and care:177 a. Diagnosis: the panel considered that Mr Wilson’s treatment was impacted by “lack of clarity regarding his diagnosis”, and 174 Exhibit 1, Vol. 1, Tab 38, NMHS Inpatient Mental Health Services Admission to Discharge, p7 175 ts 22.05.24 (Bhaduri), p108 176 Exhibit 1, Vol. 1, Tab 17.1, SAC1 Investigation Report (13.02.22) 177 Exhibit 1, Vol. 1, Tab 17.1, SAC1 Investigation Report (13.02.22), pp9-10
[2024] WACOR 27 that this had also affected the development of his risk management plan;178 b. Medication management: the panel noted Mr Wilson’s medication management was complicated by issues of noncompliance, his history of using illicit substances, and by his proclivity to alter the dosages of his medication to manage perceived side effects, without first obtaining any input from his treating team; c. Assessments: the panel found Mr Wilson’s inpatient and community assessments were comprehensive and had been informed by collateral information obtained from his mother.
The panel also noted that information (including discharge summaries) had been provided to Mr Wilson’s GP;179 d. Transfers: the panel noted that although there was evidence of communication between inpatient and community teams early in 2021, there was no documented evidence of communication during Mr Wilson’s last two admissions;180 e. Case conferences: the panel considered that collaborative case conferences would have been of benefit given “the complexity of managing this client”. However, as I have noted, Mr Wilson was an “out of area” patient at Graylands and so he was not discussed at weekly video-conferences between Graylands and its local community mental health service.
f. Referral to after-hours team: as noted earlier, the panel considered that although Mr Wilson was assessed as “low risk” when he was discharged from Graylands on 29 October 2021, he should have been followed up by the Service’s after hours/weekend team.
g. Interaction with Dr Smith: the panel noted Ms Wilson had forwarded a letter about Dr Smith’s communication style and Mr Wilson’s treatment plan.181,182 At the inquest, Dr Brett noted that communication issues of this nature can sometimes 178 See also: and ts 22.05.24 (Bhaduri), pp105-106 179 Although as noted, Mr Wilson’s discharge summary was not forwarded to the Service on 29 October 2021 180 However, see Dr Smith’s email to Dr Juniper on 29 October 2021, to which I have referred 181 Exhibit 1, Vol. 1, Tab 10, Letter - Ms A Wilson to Chief Psychiatrist (undated) 182 Exhibit 1, Vol. 1, Tab 36.1, Letter - Ms A Wilson (02.11.21)
[2024] WACOR 27 simply be a matter of the “fit” between the patient, their carer(s) and the relevant clinician.183 Although this issue is outside the scope of this inquest, I note that NMHS184 wrote to Ms Wilson to advise that although Dr Smith was no longer employed by the service, staff had been asked to provide “clearer communication when relaying treatment regimes and options”.185
The SAC1 identified two “system gaps” in relation to Mr Wilson’s care that were caused by a “lack of continuous education of staff”. The first system gap related to a lack of collaborative case conferencing and care planning between inpatient and community mental health services, which “may have contributed to fragmented care between settings and a lack of timely follow up”. The second system gap related to inadequate assessment of Mr Wilson at “different contacts with mental health services” which “may have contributed to ambiguity of diagnosis”.186
The panel also made three recommendations for improvement. The first was aimed at reminding staff of the need to comply with relevant polices relating to admission and discharge. The second focussed on ensuring mandatory education was completed and that staff skills are identified and assessed, while the third dealt with identifying and promoting training resources in relation to the MHA.187 Dr Brett’s assessment188
In his report to the Court, Dr Brett (an experienced consultant psychiatrist) reviewed Mr Wilson’s case, and his observations included: a. Diagnosis: Dr Brett noted Mr Wilson’s presentations were atypical, and that there was disagreement about his diagnosis. Dr Brett said he had “no doubt that Mr Wilson was suffering a severe mental disorder at the time of his death”, but expressed some concern about the diagnosis of schizophrenia, noting he could not find the “rationale for 183 ts 21.06.24 (Brett), p144 and see also: ts 22.05.24 (Bhaduri), p99 184 NMHS is the abbreviation for North Metropolitan Health Service, the entity responsible for Graylands 185 Exhibit 1, Vol. 1, Tab 36.2, Letter - Dr G Wojnarowska to Ms A Wilson 1(6.09.22) 186 Exhibit 1, Vol. 1, Tab 17.1, SAC1 Investigation Report (13.02.22), p10 187 Exhibit 1, Vol. 1, Tab 17.1, SAC1 Investigation Report (13.02.22), pp13-14 188 ts 21.05.24 (Brett), pp130-147
[2024] WACOR 27 the diagnosis”. Dr Brett said he would like to have seen evidence of a comprehensive developmental history, a review of Mr Wilson’s previous presentations, and “a formulation of the recent decline and multiple presentations to hospital”. Dr Brett also said he would have expected a more thorough assessment of Mr Wilson’s “personality characteristics and his coping mechanisms”, and raised the possibility Mr Wilson may have had autism spectrum disorder, although this was discounted by Dr Hodgson in his report.189,190 b. Care from July 2021: Dr Brett said Mr Wilson’s care during the four month period prior to his death was “suboptimal”, and there had not been a coordinated approach to his care. Dr Brett said there should have been increased liaison between Mr Wilson’s hospital and community treating teams, and there was an “inconsistent formulation regarding his suicide attempt”. Dr Brett also said there should have been a case conference between Graylands and the community team, and I have already canvassed the miscommunications that occurred during Mr Wilson’s final discharge from Graylands.191 c. Risk assessments: Dr Brett said he did not believe appropriate risk assessments and that the risk assessment process used was “unvalidated, not standardised, and not contemporary”. Dr Brett said that Mr Wilson required a risk formulation “explaining his previous suicide attempt and how his risk had changed”. Dr Brett said Mr Wilson also required a risk management plan “addressing his risk factors and a plan if he deteriorated”.192 d. Engagement with family: Dr Brett said he did not believe there was sufficient engagement with Mr Wilson’s family during his final admission, and that it would have been appropriate for the team social worker “or a specific carer support worker” to be involved. While I take Dr Brett’s point about the use of a social worker and/or carer support worker, I note that a family meeting attended by Mr Wilson’s mother was conducted, and that during Mr Wilson’s final admission to Graylands, she had several detailed conversations with Dr Warrington about his diagnosis and medication regime.193,194 189 Exhibit 1, Vol. 1, Tab 18.1, Report - Dr A Brett (17.10.23), pp11-15 190 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), para 17.2, p5 and ts 21.05.24 (Hodgson), p12 191 Exhibit 1, Vol. 1, Tab 18.1, Report - Dr A Brett (17.10.23), p14 192 Exhibit 1, Vol. 1, Tab 18.1, Report - Dr A Brett (17.10.23), pp14-15 and ts 22.05.24 (Brett), pp141-142 193 Exhibit 1, Vol. 1, Tab 31, Report - Dr M Warrington (19.01.24), pp5-7
In relation to Mr Wilson’s care during the period before his death, Dr Brett expressed the following opinion: I believe that in the final months of his life, (Mr Wilson’s) management was suboptimal. There did not appear to be a united approach to his formulation and management. It seems that there were a number of issues that were not properly addressed or considered.195 Dr Hodgson’s observations
In his report, Dr Hodgson referred to Mr Wilson’s complex personality structure and his various diagnoses including anxiety, bipolar affective disorder, obsessive compulsive disorder, schizoaffective disorder, and schizophrenia.196 Drawing on his lengthy experience in managing patients like Mr Wilson in the community, Dr Hodgson made these observations about the management of Mr Wilson’s mental health: Mr Wilson’s complex mental illness, his ongoing drug use, his sensitivity to medications, and his reluctance to accept the supports offered, made community management very difficult and meant that his prognosis was poor.197
Dr Hodgson said he suspected that Mr Wilson had experienced cognitive decline and associated social and occupational decline “secondary to his longstanding drug use”, and noted that Mr Wilson’s “episodes of psychosis and mania” appeared to be related to his “ongoing use of illicit substances (mainly methylamphetamine)”.198
Dr Hodgson also noted that despite the obvious impact that Mr Wilson’s substance use was having on his mental health, he routinely declined referrals to drug rehabilitation services. Mr Wilson also declined 194 Exhibit 1, Vol. 1, Tab 18.1, Report - Dr A Brett (17.10.23), p15 and ts 22.05.24 (Brett), pp143-144 195 Exhibit 1, Vol. 1, Tab 18.1, Report - Dr A Brett (17.10.23), para 22, p15 196 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), para 18.2, p5 197 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), para 20, p6 198 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), paras 18.2-18.3, p5
[2024] WACOR 27 psychological input, and/or services aimed at reducing his social isolation offered by a step down facility, and the Men’s Shed program.199
Although Dr Hodgson noted that Mr Wilson had supportive parents who were happy for him to live with them, Dr Hodgson considered Mr Wilson “may have benefitted from a long-term placement in a supported community residential unit” although Dr Hodgson felt “he would have been reluctant to accept such placement”.200 Dr Bhaduri’s observations
Dr Bhaduri (Director of Medical Services, NMHS) said that after reviewing relevant medical records, in her view the decision to place Mr Wilson on a CTO was justifiable. Dr Bhaduri noted Mr Wilson had six inpatient admissions in a four month period which indicated a “risk of rapid relapse”, and there was evidence of non-compliance with medication. Mr Wilson had also been diagnosed with a serious mental illness “characterised by psychotic symptoms, mood problems and substance use” and Dr Bhaduri noted “there was evidence that without ongoing treatment and support, Mr Wilson was at risk of significant harm to himself”.201
Dr Bhaduri highlighted the lack of direct communication with the “community consultant” regarding Mr Wilson’s transfer on a CTO, and noted this lapse had occurred because Mr Wilson’s discharge coincided with Dr Smith’s impending retirement and Dr Juniper’s “non-working day”. Dr Bhaduri also noted that “it is possible the retiring consultant aimed to minimise transitions in consultants and honoured Mr Wilson’s request for discharge on that day”.202
Dr Bhaduri commented on the findings and recommendations of the SAC1, and made the following observation about the current situation at Graylands: 199 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), paras 18.2-18.3, p5 200 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), para 18.5, pp5-6 201 Exhibit 1, Vol. 1, Tab 37, Report - Dr S Bhaduri (15.05.24), pp1-2 and ts 22.05.24 (Bhaduri), pp95-96 202 Exhibit 1, Vol. 1, Tab 37, Report - Dr S Bhaduri (15.05.24), pp1-2 and ts 22.05.24 (Bhaduri), pp96
[2024] WACOR 27 If Mr Wilson presented at Graylands Hospital today, improvements in communication between inpatient and community mental health teams would likely enhance his care, particularly in discharge planning and CTO utilisation. Revised policies now mandate verbal consultation between consultant psychiatrists, facilitating better understanding of clinical perspectives and risks.203
Dr Bhaduri noted there “increased consideration” of using after-hours teams, and the HiTH to address the concerns such as those raised by Mr Wilson and his family “regarding medication side effects and insomnia”. Dr Bhaduri also noted that the Brief Risk Assessment (consistently criticised by Dr Brett as “unvalidated, not standardised and not contemporary”)204 has been replaced by a risk assessment and management plan that “offers flexibility to develop a risk formulation”.205
Dr Bhaduri acknowledged that Mr Wilson faced challenges with various treatments and “sensitivities to medications”, and this was compounded by his serious mental illness characterised by several “somatic”206 concerns “which overlapped with some of his side effects, and needed to be treated.207
Dr Bhaduri said that with “sincere regard for the unfortunate outcome”, in her opinion, Mr Wilson’s treating team had “mostly shown inclusivity and responsiveness” to Mr Wilson and his family in relation to “medication side effects, effectiveness, and preferences. Dr Bhaduri concluded her report with the following observation: From my perspective, clinicians attempted to navigate these challenging complexities by balancing the necessity of treating (Mr Wilson’s) condition with his anxiety surrounding medication and the associated side effects.208,209 203 Exhibit 1, Vol. 1, Tab 37, Report - Dr S Bhaduri (15.05.24), pp1-2 and ts 22.05.24 (Bhaduri), pp97-100 204 Exhibit 1, Vol. 1, Tab 18, Report - Dr A Brett (17.10.23), para 20, pp14-15 205 Exhibit 1, Vol. 1, Tab 37, Report - Dr S Bhaduri (15.05.24), pp1-2 and ts 22.05.24 (Bhaduri), pp102-103 & 108-109 206 Relating to, or affecting the body, as distinct from the mind 207 Exhibit 1, Vol. 1, Tab 37, Report - Dr S Bhaduri (15.05.24), pp1-2 208 Exhibit 1, Vol. 1, Tab 37, Report - Dr S Bhaduri (15.05.24), p3 and ts 22.05.24 (Bhaduri), pp104-105 209 See also: 21.05.24 (Hodgson), p9 concerning Mr Wilson’s chronic anxiety and his proclivity to report side effects
[2024] WACOR 27 Conclusion on standard of supervision, treatment and care
Hindsight bias is the tendency after an event, to assume that the event was more predictable or foreseeable than it actually was at the relevant time.211
After carefully reviewing the available evidence, I have concluded that the decision to place Mr Wilson on a CTO prior to his discharge from Graylands on 29 October 2021 was appropriate. The CTO was justified because of ongoing concerns about Mr Wilson’s ongoing risk of suicide, and doubts about whether he would comply with his depot medication.
I have also concluded that Mr Wilson’s treatment at Graylands during his last admission was appropriate, and that his medication regime (including the commencement of a paliperidone depot, and the reduction and then cessation of his dose of diazepam) was appropriate.
Although Mr Wilson’s discharge from Graylands on 29 October 2021 was justified given the improvement in his mental state, and his desire to return home, his discharge plan was compromised. That was because prior to Mr Wilson’s discharge his consultant psychiatrist at Graylands did not speak directly with the consultant psychiatrist at the Service who would be assuming Mr Wilson’s care in the community. Although Dr Warrington was to contact the Service on 1 November 2021 to discuss Mr Wilson’s CTO and his ongoing management, Mr Wilson died before this contact could occur.212 210 (1938) 60 CLR 336, per Dixon J at pp361-362 211 Dillon H and Hadley M, The Australasian Coroner’s Manual (2015), p10 212 ts 22.05.24 (Brett), pp144-145
It is also unfortunate that Mr Wilson’s Graylands discharge summary (which contained important information about the management of his mental health) was not sent to the Service on the day Mr Wilson was discharged. Whilst the reason for this lapse has not been explained, it may have been due to workload pressures on the RMO who was responsible for preparing the summary.213
It is also regrettable that Mr Wilson and his mother were not given basic information about his diagnosis of schizophrenia, or his medication regime, including the depot injections of paliperidone he had recently been started on.214 Notwithstanding their familiarity with the mental health system, it is my view that Mr Wilson and his mother should also have been given information about the likely, or potential side effects of Mr Wilson’s medication, and concerning signs and symptoms to watch out for, as well as the pathway back to care should Mr Wilson’s mental state deteriorate.
As to whether Mr Wilson’s death could have been prevented, I note that at the time of his discharge, his risk of suicide had been assessed as “low”. Further, although Mr Wilson did appear to be experiencing some side effects from his medication after his discharge from Graylands on 29 October 2021, there is no evidence that Mr Wilson was experiencing any thoughts of suicide or self-harm, or that there were any signs he was at any acute risk in the period between his discharge and his death.
This lack of any apparent advance warning is perhaps not surprising given it is impossible to predict a person’s future risk of suicide. I have already referred to the review of suicide research referred to in Dr Hodgson’s report, where the study’s lead author (Professor Franklin) concluded that science could predict a person’s future suicidal thoughts and behaviours about as well as random guessing, before observing: “This was extremely humbling - after decades of research; science had produced no meaningful advances in suicide prediction”.215,216,217 213 ts 21.05.24 (Warrington), p63 214 Exhibit 1, Vol. 1, Tab 10, Statement - Ms A Wilson (02.11.21) 215 Exhibit 1, Vol. 1, Tab 29, Report - Dr C Hodgson (27.11.23), para 19, p6 216 See also: ts 21.05.24 (Warrington), p63, where Dr Warrington says Mr Wilson’s action were a complete shock 217 See also: ts 22.05.24 (Bhaduri), p104 and ts 21.05.24 (Brett), pp134-135
In her report, Dr Juniper made the following observations about factors that made Mr Wilson’s care and treatment more difficult to provide: I consider that this is a complex and largely a systemic issue related to resourcing and community demand for mental health services in WA, Globally, there are also challenges associated with care and treatment where multiple clinicians are involved, including clarity around diagnosis clear communication with all parties. To that end, I consider that better communication from Graylands Hospital on 29 October 2021 prior to discharge would have been optimal but that it may not have necessarily prevented (Mr Wilson’s) death by suicide.218
However, I note that at the inquest, Dr Juniper agreed that on reflection, it would have been better to have expressed the following view: “it is impossible to know whether or not it (i.e.: better communication from Graylands) would have changed the outcome in Mr Wilson’s case”.219
After carefully considering the available evidence, and having regard to the Briginshaw principle, and to the phenomenon of hindsight bias, I have been unable to conclude (to the relevant standard) that any defect in Mr Wilson’s discharge planning was causative of his death.220 The reason why Mr Wilson chose to take his life in the manner he did must remain a mystery, and this no doubt adds to the pain that his death has caused to his family and loved ones.
218 Exhibit 1, Vol. 1, Tab 32, Report - Dr A Juniper (25.01.24), p7 and ts 21.05.24 (Juniper), pp79-80 219 ts 21.05.24 (Juniper), p81 220 See also: ts 21.05.24 (Juniper), p91; ts 22.05.24 (Bhaduri), p97; and ts 21.05.24 (Brett), pp135-136
Mr Wilson’s death also highlights the ever-changing risk of self-harm and suicide associated with some mental health illnesses, and the challenges in managing those risks.221
MAG Jenkin Coroner 26 June 2024 221 ts 21.05.24 (Hodgson), p15
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