Deceased
Kimberley Michael Vulich
Demographics
64y, male
Coroner
Deputy State Coroner Linton
Date of death
2020-11-30
Finding date
2025-02-12
Cause of death
complications in association with thermal injuries in a man with underlying chronic liver disease, medically palliated
AI-generated summary
Kim Vulich, a 64-year-old man with decompensated liver cirrhosis from chronic alcohol use, developed hepatic encephalopathy and cognitive impairment including possible Korsakoff syndrome. Despite SAT guardianship orders and hospital care, he repeatedly discharged himself against medical advice from Bunbury, Collie, and Bridgetown Hospitals. On 27 November 2020, he left Bridgetown Hospital despite nursing staff raising safety concerns with the attending doctor about his confused mental state and apparent lack of capacity. Police welfare checks over the weekend were not prioritized. Two days later, Kim lit a fire in his caravan for light and heat (having no electricity) which burned out of control, causing severe thermal injuries. Key lessons: establish alert flags in digital records for patients with guardianship orders to clarify decision-making authority; improve handover communication between hospitals regarding capacity assessments and living conditions; provide secure dementia care facilities in regional areas; and ensure appropriate geriatric outpatient services can intervene before hospitalization.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
[2025] WACOR 2 (S) JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER HEARD : 5 - 6 AUGUST 2024 DELIVERED : 12 FEBRUARY 2025 FILE NO/S : CORC 2671 of 2020
DECEASED : VULICH, KIMBERLEY MICHAEL Catchwords: Nil Legislation: Nil Counsel Appearing: Mr J Tiller assisted the Coroner.
Mr M Olds and Ms J Kasbergen (SSO) represented the interests of the WA Country Health Service and the WA Police Force.
Case(s) referred to in decision(s): Nil
[2025] WACOR 2 (S) Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the death of Kimberley (aka Kim) Michael VULICH with an inquest held at the Bunbury Courthouse, 3 Stephen Street, Bunbury on 5 and 6 August 2024, find that the identity of the deceased person was Kimberley Michael VULICH and that death occurred on 30 November 2020 at Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, from complications in association with thermal injuries in a man with underlying chronic liver disease, medically palliated, in the following circumstances:
Kim Vulich was a 64 year old man who died on 30 November 2020 from complications of burns he suffered after he lit a fire in his caravan and the fire ran out of control. He lit the fire as a source of light and heat as he had no electricity.
Kim was a chronic alcoholic and he had sustained an alcohol induced brain injury and developed decompensated liver disease and other significant health issues as a result. He had spent periods of time in various hospitals in the South West in October 2020 as he became increasingly unwell and his mental capacity fluctuated. His son had been assisted to apply for guardianship orders and it was initially anticipated that arrangements would be made to move Kim in to some kind of supported accommodation nearer to where his son lived in Perth. However, while attempts were made to find a suitable place, Kim kept discharging himself from hospital and making his way back to Nannup to his caravan, which caused the police to become involved. In these circumstances, Kim’s son felt unable to fulfil his duties as a guardian, so he applied for review of Kim’s guardianship. This application was still to be heard when Kim died.
At the time of the fire, Kim had once again left hospital against medical advice and made his way back to his caravan in Nannup on his own. Kim had been evicted from the caravan park where he previously lived, so his car and caravan were parked in the street outside. Police had been notified by a concerned local after they saw Kim living in the caravan. They raised possible welfare concerns given his appearance and general manner. Local police were intending to speak to Kim when they returned to work the following Monday. Until then, over the weekend he remained living on his own in the caravan with no power. He lit a fire, reportedly for light and/or warmth, which got out of control and he suffered burns that proved fatal. The caravan was destroyed.
Following a police investigation, a report was provided to the State Coroner on 18 August 2022 setting out the circumstances leading up to Kim’s death. On 2 March 2023, I approved the holding of a discretionary inquest into the death in order to explore how Kim came to die in such circumstances, given his recent hospital admissions and known cognitive issues, as well as the concerns raised with the police about his welfare.1
I held an inquest on 5 and 6 August 2024 in Bunbury. As well as exploring the issues mentioned above, the inquest considered more broadly the services currently in place in the South West to support other people like Kim from a health, housing, guardianship and police perspective, noting that there is an increasing ageing population in this region with a corresponding increase in demand for these services.
He towed the caravan with an old Holden Commodore that he had purchased around 1 Sections 22(2) Coroners Act 1996 (WA).
[2025] WACOR 2 (S) the same time. Kim had lived in the caravan for a number of years at the Nannup Caravan Park, after moving to Nannup from the Margaret River area. Kim was a solitary person who liked to spend time on his own. He made wooden sculptures, which he sold to supplement his disability pension, and it seems he was happy living in Nannup in his caravan until his health deteriorated.2
Kim had previously been married and had a son. Kim had divorced his son’s mother when his son was young. As Kim’s son grew up, he had only semi-regular contact with Kim as at that time Kim lived in Perth and Kim’s son lived with his mother and step father in Margaret River. Kim eventually moved to Margaret River when his son was a teenager, so they had increased contact for a few years, but then Kim’s son moved to Perth and their contact again became less frequent. They still talked on the phone every few months, but did not see each other regularly in person.3
Kim’s son was aware his father had a drinking and drug problem for decades and that his alcoholism had led him to become isolated from most of his family and friends, other than Kim’s mother. In 2020, Kim’s son had been struggling to get hold of his father for some months, so when he was on a trip down south, he drove to Nannup to see him. Kim’s son found his father at the Nannup Caravan Park. They sat in the annex of his caravan and chatted. Kim didn’t invite him inside the caravan itself as he said it was too messy. Kim’s son noted his father was not looking after himself.
He didn’t look well and seemed to be disorientated and was slurring his speech. He also seemed to have trouble walking. At the time, Kim’s son thought his father might be drunk or on drugs.4
3 Exhibit 1, Tab 7.
4 Exhibit 1, Tab 7.
5 Exhibit 1, Tab 7.
[2025] WACOR 2 (S) ambulance with a nurse escort. Kim was then assessed by doctors at Busselton Hospital and diagnosed with suspected sepsis. His care was deemed too acute to be managed at Busselton, so a further transfer was arranged to Bunbury Hospital.6
Kim was in a confused mental state on arrival at Bunbury Hospital Emergency Department. He told ED doctors he had been abducted by aliens. His prior medical history was accessed to try to get an understanding of his medical issues and he was eventually assessed as having decompensated liver disease/cirrhosis and suspected bleeding oesophageal varices associated with liver cirrhosis, which had led to anaemia. He was also diagnosed with acute kidney injury and hypokalaemia (low blood potassium). It was recorded that his liver failure/cirrhosis was a consequence of heavy alcohol use and a previous diagnosis of hepatitis C (which had been treated a few years before). He was admitted to the Bunbury Hospital Medical Ward for treatment.7
Kim’s confused state on admission was attributed to possible hepatic encephalopathy. In essence, his liver had failed and it could not metabolise the waste products from digestion. This led to a build-up of metabolic products in the blood, which then altered the brain function and caused acute mood, perception and cognitive changes. Kim was noted to be disoriented to time, person and place at the time of admission, although the level of his confusion fluctuated.8
Kim was given treatment for his many physical health issues and steps were also taken to explore his cognitive issues further through consultation by mental health specialists.9
Kim’s son took his grandmother to visit Kim in Bunbury Hospital and the doctors explained that his father had some cognitive impairment and severe physical issues related to his alcohol use, including cirrhosis of the liver. It was suggested that Kim would need to go into an aged care home. Kim’s son indicated he was willing to assist in the process of trying to find some supported accommodation, although he was aware his father had little insight into his care needs and was attempting to go back to his caravan in Nannup. Hospital staff put Kim’s son in contact with a social worker from the Department of Health who could help him to get some accommodation funding for his father through the NDIS.10
On 26 October 2020, Consultant General Physician Dr Stephen Hinton took over Kim’s care. Dr Hinton continued to have oversight of Kim’s care until he left Bunbury Hospital a little over three weeks later. Dr Hinton was aware Kim was being treated for liver failure and noted that Kim had made good progress, but he had not completely recovered yet and was still in a decompensated state, which was impacting his mental function. He had not fully come out of his delirium at that time.
Dr Hinton’s observations were that Kim’s mental state was one of variability, and he considered this was primarily due to hepatic encephalopathy. Dr Hinton gave 6 Exhibit 1, Tab 21, Tab 23, Tab 24 and Tab 34.
7 Exhibit 1, Tab 34.
8 T 28 – 29; Exhibit 1, Tab 34.
9 Exhibit 1, Tab 25.
10 Exhibit 1, Tab 7.
[2025] WACOR 2 (S) evidence that even when Kim’s condition improved, he was always at risk of the hepatic encephalopathy recurring, and it could happen quite quickly. In addition, it was possible he had developed a certain amount of permanent brain damage from having had chronic hepatic encephalopathy over a period of time. He also had vascular disease, so there was a suspicion this was contributing to his dementia as his brain scan showed white matter changes.11
Dr Hinton observed that Kim’s mental scores were improving as his liver disease was treated, but how much was due to the treatment of the hepatic encephalopathy wasn’t entirely clear. It is clear that Kim became increasingly unhappy as the length of his admission increased and his mental state improved. He was seen by Dr Hinton on the morning of 29 October 2020, and it was noted that his initial acute confusion due to his liver failure had resolved, but he was filling in stories with confabulation where he had memory gaps. This suggested he might have an additional diagnosis of Wernicke-Korsakoff syndrome as the confabulatory characteristic are frequently seen in Korsakoff’s psychosis. Dr Hinton explained at the inquest that it is usually a combination of malnutrition and alcohol use that leads to Korsakoff syndrome, which was consistent with Kim’s history. Dr Hinton asked for a psychiatric review to be arranged. At that stage, Dr Hinton still considered Kim had a number of outstanding medical issues and was not fit for discharge, so it was not planned to transition Kim to being a psychiatric patient at that stage. Rather, the psychiatric referral was simply to try to look for an explanation for his ongoing cognitive issues and explore the possible Korsakoff’s diagnosis.12
Kim was reviewed by a Psychiatric Liaison Nurse (PLN) later on 29 October 2020.
He vented his frustration, complaining that he had come in for an anticipated admission of two to three days, but was still there four weeks’ later. He also complained the noisiness on the ward was negatively affecting his sleep and mood and that he did not have his dentures. Kim said he was usually a positive person, but the hospital was getting him down. He gave some possibly delusional answers to questions and it was felt he required further review. He was seen again by a PLN on 3 November 2020 and was noted as showing obvious signs of cognitive impairment and a decline in level of functioning at that time, but no evidence of any major mental illness.13
12 T 30 - 31; Exhibit 1, Tab 25.10.
13 Exhibit 1, Tab 25.8, Progress Note of PLN, 29.10.2020.
14 Exhibit 1, Tab 20.
Police made enquiries with family members and it was suggested he might have tried to go to his mother’s house (although she was also a patient in hospital at that time) or back home to Nannup. Police made extensive efforts to locate Kim and eventually found him in his bed in his caravan in Nannup at about 8.30 am. He told police he had walked out of the hospital and got a lift from a man back to Nannup. The Incident Report indicates Kim refused to voluntarily go back to Bunbury Hospital, but he did agree to go to Nannup Hospital to have his catheter removed and to be checked over. He was taken by police to Nannup Hospital without any issues and initially left in the care of hospital staff.15 A Form 1A under the Mental Health Act (MHA) was then completed by a doctor, after which Kim was returned to Bunbury Hospital by police.16
Kim was assessed by a senior medical officer from the psychiatric team, Dr Khoja, later on the morning of 4 November 2020. He was oriented to time and place (an improvement on his earlier psychiatric assessments) and there was no evidence of psychotic phenomena, although his account of his history appeared confabulated and unreliable. Brief bedside cognitive testing suggested mild to moderate impairment and his capacity to consent to ongoing care was felt to be questionable. Further assessment of his cognitive impairment by the geriatric team was recommended, and a second psychiatric opinion was also sought before a decision to revoke the Form 1A was made.17
Kim was reviewed again by Dr Khoja along with Consultant Psychiatrist Dr Sketcher the following day. Dr Sketcher observed no evidence of a treatable mental illness and found no identified grounds to continue detaining him under the MHA, so the Form 1A was rescinded. However, given Kim’s obvious cognitive impairment and questionable thought content, Dr Sketcher supported referral to the State Administrative Tribunal (SAT) for consideration of guardianship along with a functional assessment to assess his fitness to self-care at home and fitness to operate a motor vehicle.18
Dr Hinton assessed Kim again on 9 November 2020. Kim presented with the same issues and Dr Hinton began to form the impression that Kim had a permanent form of mental impairment as his initial confusion due to liver disease had resolved with treatment, but his cognitive capacity continued to vary considerably. At times he was rational and showed normal capacity to understand issues involving his health, but he continued to make claims about his past that were not supported and this confabulation suggested a degree of permanent Korsakoff’s psychosis. Accordingly, Dr Hinton asked that Kim be assessed by a psychiatrist, a geriatrician, an occupational therapist and staff from the Subacute and Restorative Unit.19
The Subacute and Restorative Unit primarily provides geriatric services for older patients’ post-acute care, where patients have not achieved the baseline to go home so they require intensive rehabilitation by an allied health team before discharge.
15 Exhibit 1, Tab 13.
16 Exhibit 1, Tab 20.
17 Exhibit 1, Tab 20.
18 Exhibit 1, Tab 20.
19 Exhibit 1, Tab 25.10.
[2025] WACOR 2 (S) Kim was found unsuitable for the unit due to his behavioural issues, although they thought he had capacity. However, Dr Hinton was still concerned about Kim’s cognitive capacity, so he continued with the psychiatric assessment.20
Dr Carrigan had been asked to assist the psychiatric team in the review due to his expertise in cognitive impairment. Kim did not display significant cognitive issues during the assessment, but it was noted his pattern appeared to fluctuate. He was oriented to time and place and had some insight, although he persisted in some unusual beliefs or statements about his history (confabulation), which suggested either a personality disorder or acute brain pathology. Dr Carrigan agreed with the overall impression of delirium in the context of liver failure associated with excessive alcohol use, with the possibility of underlying cognitive compromise related to Alzheimer’s/vascular dementia or Korsakoff’s syndrome (which is dementia related to chronic alcohol use). He considered Kim showed signs of baseline mild to moderate cognitive impairment at the time of review.22
Dr Carrigan explained at the inquest that Kim had improved with medical treatment, hydration and good nutrition in a stable location where he could orient himself, but there was a significant risk he would deteriorate quite quickly if he left the hospital and his medication regime and nutrition became compromised again.23 There was a consensus amongst the medical practitioners treating Kim that it was not safe or appropriate for Kim to be discharged to his caravan on his own and that he required formal support in the form of a guardianship order.
Bunbury Hospital staff assisted Kim’s son to apply to become his father’s guardian.
Dr Hinton completed a SAT medical report in support of the application. The guardianship and administration application noted that Kim was still a patient in Bunbury Hospital at that time. He had been told that he was not medically well enough to care for himself and needed to stay in hospital until he could transition to an appropriate setting, such as a nursing home. Informal arrangements to keep him in hospital until that could occur had not been successful as he had indicated he wanted to leave, despite his poor health, and had escaped from hospital and also discharged himself from hospital against medical advice. It was noted that there was a risk that if he absconded from Bunbury Hospital again, he would pose a danger to himself and possibly to others, for example if he were to drive a vehicle. It was also noted that he had not maintained his own caravan or car and he often forgot to complete tasks, which meant there was a risk of neglect if he was left to manage on his own.24
21 Dr Carrigan is an older adult psychiatrist who treats elderly people with mental health issues who are either over 65 years, or are Aboriginal and Torres Strait Islander and over 55 years of age.
22 T 13 – 14, 17 - 19; Exhibit 1, Tab 20 and Tab 21.
24 Exhibit 1, Tab 18, Tab 20 and Tab 25.
• to decide where he was to live, whether permanently or temporarily; and
• to determine the services to which he should have access.
Kim’s son had made it clear at the hearing that he wanted his father to live somewhere that he was happy but recognised that his father could no longer safely live by himself in the caravan park and needed to live somewhere where he could receive a little more support. He was planning to explore options with the hospital staff once guardianship was granted. The orders appear to have been made on the basis that everyone hoped to work together to find somewhere for Kim that was safe and stable but where he was also happy to voluntarily reside, so that the guardianship and administration orders could then end after a year or so. Kim had indicated at the hearing he was happy with the orders being made in those terms and was hopeful he could find somewhere suitable in Perth nearer to his son.26
The appointment notably did not include any powers to make decisions around his father’s medical care. The information provided by his treating doctor, Dr Hinton, had indicated that he was unsure whether Kim had the capacity of thought and reasoning to make appropriate treatment decisions for himself, although it was clear he lacked insight about his overall wellbeing and the consequence of his illness.
Based on this information, the Tribunal member indicated they were satisfied this decision-making function should continue to rest with Kim.27
Dr Hinton gave evidence he was content with the outcome and felt Kim generally was reasonable in terms of his decision-making around what medical therapy he was willing to accept. The primary concern was around his unwillingness to stay in hospital in order to continue to receive treatment. Kim’s treating team at Bunbury Hospital interpreted the order as indicating that Kim could make decisions around his medical treatment, but Kim’s son needed to be consulted with respect to decisions about where Kim was to live, whether temporarily or permanently, which included whether Kim could then leave hospital. This seemed a practical way to ensure he stayed safe while he was stabilised. A security guard was stationed near Kim’s room so that if he attempted to leave, the security guard could notify hospital staff and the hospital staff could then encourage him to remain in hospital where he would be safe.28
Kim’s son was aware that his father was difficult to handle, sometimes abusive towards staff and an absconding risk while at the hospital, and that he required ongoing supervision and support. However, at that early stage he probably didn’t understand fully how onerous the role of guardian would be for his father when a place could not be found for him. Kim’s son stated he had discussed with the hospital staff appropriate accommodation for his father to live in after he was discharged 25 Exhibit 1, Tab 7, Tabs 19 to 21.
26 Exhibit 1, Tab 21.
27 Exhibit 1, Tabs 20 to 21.
28 T 37; Exhibit 1, Tab 25.10.
[2025] WACOR 2 (S) from hospital, and they had agreed it was not appropriate for Kim’s son to try to care for him at home due to his behavioural issues. Rather they began to try to find some kind of aged care home or supported accommodation that would be suitable for him.
If that could not be achieved by the time Kim’s liver failure had stabilised, then it was planned he would be transferred to an outlying hospital where he could wait until supported housing was found.29
After a 38 day admission to Bunbury Hospital, Kim transferred to Collie Hospital on 18 November 2020 and was admitted under the care of Dr Basudeb Saharay.30
The discharge summary indicated that Kim’s son had been appointed as his guardian for financial matters only. It was noted in the discharge summary that as Kim had been deemed to have capacity to make his own medical decisions at the SAT Hearing, he was no longer being ‘specialled’ and could not be detained under duty of care unless he was to become encephalopathic again. Kim had participated in completing a goals of care form with Bunbury Hospital staff and he had indicated that ward-based care be the ceiling of treatment.31 For the benefit of the Collie Hospital staff, a special point of concern was also identified in the paperwork that, due to his organic brain injury, Kim could be verbally inappropriate at times, particularly towards female staff members.32
Kim was noted on 19 November 2020 to have settled into the ward. The next day he was alert and orientated and was tolerating diet and fluids but was rude and abusive to staff at times. He was seen by a social worker, who felt Kim engaged well. Kim made it clear he was keen to leave hospital and move into independent living in Perth, to be closer to his son, as soon as possible. The social worker contacted Kim’s son, who advised he had spoken to a number of places in Perth but they all had a three to four month waiting time. It was agreed that the social worker would explore more local options in the South West, to see if any placements might become available sooner. 33 29 Exhibit 1, Tab 7.
30 T 31 – 32; Exhibit 1, Tab 7 and Tab 25.
31 Exhibit 1, Tab 25.2.
32 Exhibit 1, Tab 25.2.
33 Exhibit 1, Tab 27.
Senior Social Worker Catherine Kelly gave evidence at the inquest that a social worker from her team had discussions with Kim’s family around placement options and safe discharge planning for Kim, but they were still exploring options when things escalated.34
Kim continued to be managed on the ward over the following days. He was generally compliant with nursing staff but was noted to be hard to manage at times and sometimes disruptive. At some stage he asked the security guard for a lift after his shift finished. Kim signed a DAMA (discharge against medical advice) overnight on 23 to 24 November 2020 and then discharged himself at around 6.30 am on the morning of 24 November 2020. Kim’s son was advised by a nurse that Kim had discharged himself and that the doctor had advised that the hospital staff could not make him stay, or return, against his will. The nurse told Kim’s son she would try to locate Kim and he mentioned Kim had previously left Bunbury Hospital and made his way independently to Nannup. The nurse rang the Nannup Caravan Park and was advised Kim had indeed returned there. They had given him his car keys and were not sure where he had gone after that. Kim’s son was informed and police were contacted. Officers from Manjimup Police Station attended as the Nannup police officers were busy. He was spoken to by two police officers and they held no immediate concerns for his safety and left him there.35
Senior Social Worker Catherine Kelly recalled she received a call from Collie Hospital staff saying that the police wouldn’t bring Kim back and asking her for assistance as to what they could do next. Ms Kelly rang the police to get some clarification and they confirmed they held no immediate concerns for Kim’s safety and, therefore, they considered they had no power to return him to the hospital. Ms Kelly then spoke to Mr Richard Arnold from the Older Person’s Initiative, to see if he could help her to understand the terms of the guardianship order and determine whether Kim had capacity to make decisions for himself or not. She was informed that Kim’s son was his guardian administrator in relation to his accommodation and services but not in relation to medical decisions. Ms Kelly explained at the inquest this was a more complex matter than she had previously been involved with in terms of the guardianship order terms, which caused some confusion moving forward . She noted it also seemed that Kim’s son was overwhelmed by the complexities, and when she spoke to him, he told her it was more complicated than he had anticipated.36
On 25 November 2020 police received another call from Collie Hospital advising that Kim had discharged himself from hospital against medical advice and hospital staff had concerns for his safety as Kim didn’t have his medication with him. They advised he did not have capacity to make safe decisions for himself and his son had been appointed as his guardian.37
A police officer involved in task vetting at the Police Assistance Centre in Perth called Kim’s son and discussed the situation. The police officer recorded that Kim’s
35 Exhibit 1, Tab 27.
36 T 73 – 76; Exhibit 1, Tab 29.6.
37 Exhibit 1, Tab 14.
[2025] WACOR 2 (S) son requested that police take his father to hospital as he was not in Nannup and could not easily assist. He was advised the police did not have the authority to compel Kim to go to hospital and it was not a police matter. Instead, the police officer suggested he call the caravan park and request the staff keep an eye on his father and then arrange for a taxi to take his father to hospital. In the meantime, Kim went to the local pharmacy to try to get his medications dispensed.38
When Kim attended the local pharmacy, the pharmacist became concerned for his welfare and arranged for Kim to be taken to Nannup Hospital. Kim told the Nannup Hospital staff that he had no medications, food or money. He advised he had discharged himself from Collie Hospital and hitchhiked back to Nannup. He looked unkempt and was still wearing pyjamas. He complained that he was in pain as his back was hurting after helping a nurse with a patient previously. Nannup nursing staff spoke to a social worker who had been involved in Kim’s care and then Kim was persuaded that he needed to go to Bridgetown Hospital so that he could get his medications prescribed. He was transferred in a hospital car with a nurse escort and admitted to Bridgetown Hospital on the afternoon of 25 November 2020 as he was noted to be incapable of self-care.39
Dr William Dewing has been working as a general practitioner in Bridgetown for 46 years. He reviewed Kim at this admission on 25 November 2020 and recalled that Kim had been treated in Bunbury Hospital for hepatic encephalopathy and anaemia and then been transferred to Collie Hospital, where he had discharged against medical advice. Bridgetown staff had limited information about his capacity issues, but enquiries established his son was his guardian. Kim was kept in Bridgetown Hospital overnight, his medications were reinstated, and a social worker advised Bridgetown Hospital staff that they would be conducting a case meeting the next day with Kim’s son to try to do some future planning for Kim.40
In order to try to find a path forward, Ms Kelly arranged a teleconference with Kim and a social worker assisted him on site at the hospital to participate on 26 November
Kim’s son was invited to participate in the meeting, but he declined. Instead, on 26 November 2020, Kim’s son lodged an application to review the guardianship and administration order that had been granted to him in relation to his father. He explained in the application that he was no longer able to fulfil the requirements of the role and was seeking that the order be transferred to the Office of the Public Advocate. Kim’s son indicated he was still committed to helping his dad and making sure he was safe, and felt confident his father’s level of cognitive ability had significantly improved and he would be able to participate meaningfully in decisionmaking with a court appointed advocate. The application was still to be heard at the time of his father’s death, a few days later.41 38 Exhibit 1, Tab 14 and Tab 33.
39 Exhibit 1, Tabs 28 to 29.
40 T 46 – 47; Exhibit 1, Tab 29.
41 Exhibit 1, Tab 22.
Ms Kelly gave evidence at the inquest that there had also been some planning around Kim having to pay some fees to cover his care while he remained in hospital, but the records show that while this was being arranged, it does not seem that this had been discussed with Kim. If he had been told he would have to start paying, it is likely this would have further pushed him towards trying to leave, as he seemed generally concerned about his limited finances, but given the evidence such a discussion would be documented and there was no record in the notes, I don’t find this was a factor at the relevant time. In any event, there was evidence the fee can be waived if there is a financial hardship, so if it was raised with Kim, I’m sure there would have been discussions about how he might avoid paying it if he couldn’t afford it.42
He was given pain medication for his back pain and appeared to spend most of the day sleeping. He was seen by a social worker late in the morning and the social worker noted concerns that Kim might DAMA given his history. Kim expressed concerns about a cancelled bankcard, so the social worker helped him to contact his bank. They discussed the attempts to find a new place for him to live and Kim appeared to understand that his son was trying to find somewhere suitable for him.
Kim became restless that evening as the paracetamol wasn’t working, so he was suffering a lot of pain.43
The next day, being 27 November 2020, he was charted for oxycodone, which had a good effect and his pain greatly reduced. Kim was noted to be generally alert and orientated to place when seen just after lunch, although a little vague. He was settled for most of the day but then became unsettled when told not to touch staff and he eventually asked to self-discharge. Another general practitioner, Dr Morling, was on site and aware that Kim wanted to DAMA. Dr Morling advised nursing staff to allow this to occur and Kim left the hospital.44
Sadly, Dr Morling had passed away prior to the inquest, but Dr Dewing gave evidence to provide some context to these events. Dr Dewing explained that it is extremely difficult to manage disruptive patients with delirium or a confused mental state in Bridgetown Hospital due to personnel issues and the design of the building, which is not secure. Generally speaking, they can do it for short periods by bringing in security staff to sit with the patient and prevent them from absconding, but longer term they usually send them to Bunbury Hospital. In this case, Dr Dewing noted that the Bridgetown Hospital staff had done their best to keep Kim calm and happy and manage his back pain, but his behaviour continued to escalate to a point he couldn’t be managed there. In terms of options, it was really only to send him to Bunbury Hospital or let him leave. Kim had been transferred out of Bunbury Hospital and wasn’t willing to return there voluntarily. The Bridgetown staff were aware that he was allowed to make his own medical decisions and both Dr Dewing and Dr Hinton 42 T 20 – 21, 78 – 80, 87 - 89; Exhibit 1, Tab 36.
43 Exhibit 1, Tab 29.
44 Exhibit 1, Tab 29.
[2025] WACOR 2 (S) had formed the impression he had the capacity to do so at the time. Accordingly, Kim was permitted to decide to discharge himself and his son was informed.45
Later on the evening of 27 November 2020, Kim was found by a member of the public near the Bridgetown Tennis Courts, about 200 metres from Bridgetown Hospital, after he had apparently taken a tumble from his walker and then called out for help. He did not appear to have any injuries but they were concerned for his welfare so local Bridgetown police officers were notified. Senior Constable Ben Ducker, who attended the job, recalled Kim was cooperative with the police officers but he presented as a little strange in his manner and they had concerns about his capacity and decision-making capability due to his manner and behaviour. They took Kim back to the hospital, although they noted he had not been reported missing from the hospital at that time.46
Kim was spoken to by nursing staff and he agreed to stay in his room overnight. Kim indicated he understood that if he was disruptive, he would be discharged from the hospital, as per Dr Morling’s instructions. He was given some pain relief and then settled down to watch television. He remained in his room overnight.47
The progress notes record that the next morning at 8.45 am Kim stated he wanted to go home to Nannup on the bus, which he believed was leaving Bridgetown at 9.00 am. Registered Nurse Carolyn Moyses was working that morning as the shift coordinator, having commenced her shift at 7.00 am. She had not met Kim previously but became involved in his care that day as coordinator when informed that he was trying to leave the hospital. Nurse Moyses found Kim in the corridor. He attempted to get past her but she stopped him to discuss what he was intending to do.
When he mentioned his plans to take the bus, Nurse Moyses tried to explain to Kim that the 9.00 am bus went to Bunbury, not Nannup. She also queried how he thought he would catch the bus without any money. However, he was adamant that the bus would take him home to Nannup for free. Nurse Moyses recalled thinking that he wasn’t in a rational state of mind at the time and seemed fixated on getting home.
Not long after their conversation, Kim walked out of the hospital, heading towards the highway, still dressed in his pyjamas. It appeared to the nursing staff that he had taken all of his belongings with him and wasn’t planning to return. The nursing staff had not tried to stop him given the doctor’s instructions that he was free to go.48
46 Exhibit 1, Tab 12.
47 Exhibit 1, Tab 29.
48 T 60 - 61; Exhibit 1, Tab 29.
[2025] WACOR 2 (S) admission. He indicated that Kim was legally allowed to leave the hospital and told Nurse Moyses that Kim was “free to go whenever he chooses”49 and the police should not be requested to return him to the hospital.
Nurse Moyses stated she felt disappointed about what she felt was a lack of care and concern for Kim at that stage.50 She couldn’t understand why Dr Morling was unconcerned, given the risk of Kim coming to harm walking along the highway and generally felt he didn’t take the matter seriously.51 Nurse Moyses told Dr Morling she still planned to call the local police and update them on the situation, as it was likely they would be notified by a member of the public anyway, given how he was dressed and his general demeanour. Nurse Moyses tried to call the police on the nonurgent police number but was unable to get through after waiting for five minutes, so she then left it and made an entry in the integrated progress notes documenting her involvement thus far.52
Nurse Moyses recalled she was informed by another nurse at about 9.15 am that the Bridgetown police were not on duty until 4.00 pm that day, and the report in relation to Kim was not deemed to be a priority by police.53
Dr Morling made an entry in the medical records at 12.30 pm on 28 November 2020 noting that Kim had been causing a lot of trouble on the ward before he had DAMA.
The doctor noted that his blood results had shown no acute medical abnormality and he did not think that Kim medically needed admission. Rather, he understood it was a social admission as Kim was essentially homeless.54 Dr Carrigan, who reviewed this matter, noted that the tribunal decision that Kim had capacity in relation to health decisions did constrain what Dr Morling could do, as he was at risk of censure if he ignored that finding,55 so his conclusion was reasonable in the circumstances.
Dr Dewing gave evidence that, in his experience, the local Bridgetown police were always very helpful and the hospital staff relied on them enormously when patients absconded or required transport.56 However, in this case Kim was allowed to leave, so there was no urgent need for the police to take action. As to Dr Morling’s decision, Dr Dewing observed that in hindsight, it might have changed if there had been a better understanding of the living conditions Kim was returning to, but they had no information about his home circumstances at the time. However, the doctors were also constrained by Kim’s apparent capacity to make medical choices, which made it difficult to impose decisions upon him that might have made him safer, but would have taken away his right to choose.57
Kim’s son had spoken to his father on the phone when he first arrived at Bridgetown Hospital on 25 November 2020 and he recalled that his father had seemed really
50 Exhibit 1, Tab 29.5 [29].
52 Exhibit 1, Tab 29.
53 Exhibit 1, Tab 29.5.
54 Exhibit 1, Tab 29.
[2025] WACOR 2 (S) happy as he had a private room and the food was good. Kim’s son understood the plan was for his father to remain there until a placement in an appropriate facility became available. However, Kim’s son then got the call from the hospital a few days later advising him that his father had escaped from Bridgetown Hospital and was seen hitchhiking on the highway. He understood that the local Nannup police had been advised.58
A nursing note records that Nurse Moyses informed Kim’s son sometime before 2.00 pm that Kim had left the hospital and there were concerns for his safety. Kim’s son had indicated he would speak to his mother, who lived in the South West, to see if she could assist. The nursing entry recorded that the police had been informed and they did not deem it a priority to attend, and Dr Morling had formally discharged Kim, so he was no longer a patient of the hospital.59 Nurse Moyses finished her shift at 3.30 pm and had heard nothing further in relation to Kim before the end of her shift. Nurse Moyses said there wasn’t much else she could do at that stage and she assumed someone would eventually go to Kim’s assistance, given the police and his family were aware he had left the hospital.60
Senior Constable Ducker recalled that the day after he returned Kim to the hospital, there was a call from Bridgetown Hospital staff to the local police station advising that Kim had left the hospital again. They were not immediately recalled to attend, but at 4.00 pm the local police began to make enquiries. Another job then came in advising that Kim had already made his way to Nannup, so they passed the incident over to the Nannup local police for them to decide on attendance.61
The officer suggested that Kim’s son might consider driving down to Nannup to check on his father.62
59 Exhibit 1, Tab 29.
61 Exhibit 1, Tab 12 and Tab 16.
62 Exhibit 1, Tab 7.
63 Exhibit 1, Tab 7.
64 Exhibit 1, Tab 7.
A number of people staying at the Nannup Caravan Park heard an explosion and then a man calling for help at about 1.00 am on 30 November 2020. They got up and approached Kim’s burning caravan, which was parked on Brockman Street. They found Kim lying on his back, in what appeared to be a garden bed, about five metres to the left of the fire, which was still burning fiercely. One of them called triple zero while the others spoke to him and asked him his name. He told them his name was Kim and that he was really burnt and couldn’t move further away from the caravan to safety due to the pain of his injuries. Some of the bystanders then walked over and carried Kim to safety. They could see he had suffered full thickness burns to his body but he was conscious and appeared to be breathing normally. Kim mentioned that he “didn’t have any electricity and couldn’t see anything so he lit a small fire so that he could see.”66 They provided first aid to Kim by pouring water on his burnt skin until an ambulance arrived and ambulance officers took over his care.67
Police officers attended and found no suspicious circumstances. It appeared the fire was accidental. Kim indicated he had lit a fire in his caravan to keep warm and for light. The fire had got out of control and when he tried to escape, he fell into the fire and set his clothing on fire. He managed to escape the caravan and rolled on the ground to extinguish the flames, but not before he had been badly burnt to around 40% of his body.68 Arrangements were made to airlift Kim by helicopter to the Burns Unit at Fiona Stanley Hospital in Perth.
Kim was triaged at Fiona Stanley Hospital at 6.00 am on 30 November 2020. He was intubated and ventilated on arrival and was given pain relief before being assessed by a burns consultant at 6.30 am. His prognosis was very poor. Following discussions
66 Exhibit 1, Tab 8 [31].
67 Exhibit 1, Tabs 8 to 10.
68 Exhibit 1, Tab 17 and Tab 31.
[2025] WACOR 2 (S) with Kim’s son, he was extubated and kept comfortable until he died at 10.30 am that morning.69
Police officers attached to the Arson Squad examined Kim’s burnt-out car and caravan. The caravan had not been attached to the Holden Commodore at the time the fire ignited, although they were parked close to each other. The fire had been extinguished by crews from the Nannup Volunteer Fire and Rescue Service but both the caravan and the car were completely destroyed in the explosion and subsequent fire, with only the steel framework remaining. Due to the extent of the damage, the exact ignition point for the fire could not be established, but the origin of the fire was somewhere within the interior of the caravan, which was consistent with Kim’s statement to witnesses at the scene that he had deliberately lit a fire inside as a light source. All the evidence pointed to an accidental death.71 Based upon the known circumstances, I find that the manner of death was by way of accident.
Given there were several requests by hospital staff and members of the public for police to conduct a welfare check on Kim, prior to his death, I requested the WA Police Force Internal Affairs Unit (IAU) review the police interactions with Kim and consider whether the conduct of the police officers involved complied with WA Police policies and procedures. The IAU review included the relevant CAD tasks and other relevant materials, such as the Bridgetown Hospital medical records.72
There were two CAD jobs on 4 November 2020, when Kim absconded from Bunbury Hospital and was eventually returned, via Nannup Hospital. These CAD tasks were responded to appropriately and without incident. Police also responded promptly to a welfare check request on 24 November 2020, when he had left Collie Hospital and returned to his caravan. A request the next day from hospital staff led to 69 Exhibit 1, Tab 32.
70 Exhibit 1, Tabs 5 to 6.
71 Exhibit 1, Tab 11.
72 Exhibit 1, Tab 33.
[2025] WACOR 2 (S) a police officer calling Kim’s son and suggesting he make arrangements for his father to be taken to hospital as it was not a police matter. However, events were overtaken by Kim presenting to the local pharmacy in a dishevelled and confused state, ultimately leading him to being taken back to Nannup Hospital and then transferred to Bridgetown hospital that night. The IAU considered the steps taken by police were reasonable in the circumstances.73
The IAU review identified that local police in Bridgetown and Nannup were contacted three more times to perform welfare checks on Kim on 27 and 28 November 2020, before being notified that his caravan was on fire in the early hours of the morning on 30 November 2020. These interactions were significant, given the final tragic events.74
The first CAD job was created at 9.51 pm on Friday, 27 November 2020, a little under an hour after Kim discharged himself from Bridgetown Hospital. Police officers were told he had fallen and was in distress near the tennis courts. Police attended quickly and thought he had a strange manner but were aware that he was in hospital on compassionate grounds only and felt he did not appear to warrant apprehension under the Mental Health Act. However, Kim agreed to return to the hospital voluntarily, so they returned him to the care of hospital staff. The IAU investigators were satisfied the police response to this task was appropriate.75
When Kim left Bridgetown Hospital again the next morning, a nurse from Bridgetown Hospital advised police that Kim had left the hospital and was trying to walk to Nannup. A CAD job was created at 12.41 pm on Saturday, 28 November
The Police Assistance Centre (PAC) in Perth contacted the hospital and ascertained that Kim had left the hospital voluntarily and had been medically cleared for discharge by a doctor. The PAC call taker reached the conclusion it was not a police matter but did contact the Officer in Charge of Bridgetown Police, Sergeant Phillip Nation, at 1.12 pm to advise him of the situation. Sgt Nation was aware of the previous incidents with Kim and believed police had no power to compel Kim to return to hospital at that time. As a result, police did not attend to the CAD task at that time, and the task was updated with information that there appeared to be no viable police action to be taken at that stage. No Bridgetown police officers were on duty at the time, but the task was flagged for review when Bridgetown police officers commenced duty at 4.00 pm that day. No other calls were received and Kim managed to get home to Nannup, so nothing more was done by Bridgetown police on the task that day.76
Having apparently hitchhiked back to Nannup, Kim had returned to his caravan that was parked in the street and been seen by a concerned member of the public. The member of the public rang police at 5.38 pm on the Saturday evening. The caller reported welfare concerns for Kim as he seemed to be living in an abandoned caravan and appeared feeble and unwell with possible mental health issues. The caller suggested if police attended then he could show them to the caravan. The CAD 73 Exhibit 1, Tab 33.
74 Exhibit 1, Tab 33.
75 Exhibit 1, Tab 33.
76 Exhibit 1, Tab 33.
[2025] WACOR 2 (S) task also included information that Kim had asked the caller for help with starting his vehicle, which didn’t appear road worthy.77
This new CAD task was immediately identified as being connected to the earlier CAD task from that day. The Police Operations Centre (POC) Radio Supervisor contacted the Officer in Charge of the Nannup Police Station, A/Senior Sergeant McNevin, to advise him of the incidents. It was a Saturday night and Nannup Police were not on duty at the time and were not due to commence work again until 7.00 am on Monday, 30 November 2020. Sgt McNevin told the radio supervisor that Kim was known to him and that he considered it was not a police matter. The radio supervisor made a note that the job was to be closed, and the CAD task was then closed at 6.00 pm without any police attendance to Kim in response to the welfare check request.78
Sergeant McNevin had commenced as the OIC of the Nannup Police Station on 15 April 2019 and he had got to know Kim as a resident at the local Nannup Caravan Park. He had last seen Kim about two weeks prior to the caravan fire, at which time Kim had seemed jovial and pleasant. He told the IAU investigators that it was clear to him that Kim had some underlying medical conditions, but he had thought Kim still seemed in reasonable health at that time and he had formed the impression that Kim was a “fairly tough old guy who had a hard life.”79 Sgt McNevin was not aware at the time that Kim had been in and out of hospital recently and hadn’t thought that Kim looked like he needed medical attention when he saw him last. When he received the call from the POC radio supervisor, he had thought the information he was given was fairly consistent with what he knew about Kim and his living arrangements and it did not raise any immediate concerns in his mind for Kim’s welfare. As a result, he believed there was no need to recall officers to attend immediately. He had planned to catch up with Kim personally when he returned to work on the Monday morning, but obviously events intervened before that could occur.80
There are only two officers based at Nannup Police Station so it is not a 24 hour, seven days a week police station. Sgt McNevin explained that there was a lot of community policing involved in the role and one of the most common tasks that he was allocated was welfare checks, which is also one of the most common tasks for most police officers when on duty at police stations in WA and has only increased since the COVID-19 pandemic.81
It was noted by the IAU investigators that on 24 November 2020, Collie Hospital staff had expressed concern that Kim had returned to his caravan, which had no power. It seems, therefore, there was some information available at the time of 28 November 2020 that could have flagged this as a potential issue for Kim, but there is no evidence to suggest Sgt McNevin was aware that Kim had been evicted from the caravan park and was living in it without power.82 77 Exhibit 1, Tab 33.
78 Exhibit 1, Tab 33.
79 T 112; Exhibit 1, Tab 33, p. 6.
80 Exhibit 1, Tab 33.
82 Exhibit 1, Tab 33, p. 3.
Sgt McNevin explained at the inquest that he understood Kim was still living in the caravan park and he assumed the caravan park owners would have contacted him if they had any concerns about Kim. Sgt McNevin would regularly visit the caravan park and speak to the managers in order to monitor the number of visitors in the park and prepare for any possible issues. He had first become aware of Kim living there when one of the managers told him that Kim had moved in and had some issues with his car. Sergeant McNevin had returned to the caravan park a few days later and seen Kim’s car, which was in a state of disrepair and the exhaust, in particular, was illegal as it was dragging on the ground. Sgt McNevin has experience in mechanics, so he very kindly offered to fix it. Sgt McNevin returned on another day and fixed the exhaust and ignition on the car as Kim was having trouble starting it.83
The CAD job indicates that there was mention from the caller that Kim wanted help starting his car. Sgt McNevin gave evidence he assumed that since he had helped repair Kim’s car in the past, he thought Kim simply wanted the same kind of assistance again. Sgt McNevin said he planned to assist Kim with repairing the car if he could, but didn’t consider it a matter of urgency. Accordingly, he told the POC officer that he would help Kim when he was back on duty on the Monday.84
Sgt Alan Becker, the Death in Custody Coordinator at IAU and Det Sen Sgt Craig Annesley, also from IAU, concluded that the WA Police decision not to attend Kim’s caravan immediately, and rather to wait until Nannup police officers were back on shift on the Monday morning, was reasonable in the circumstances and based on the known information at the time. It was also suggested in the IAU report that there is no evidence that the decision of police not to attend is connected to the fire incident that caused Kim’s death.85 I’m not necessarily persuaded that the decision by police not to attend immediately can be said to have no connection to Kim’s death, in the sense that there is a possibility that if police officers had attended that night, they may have appreciated that Kim’s caravan was no longer in the caravan park and was now in the street, unconnected to power or water and potentially an unsafe environment for him. However, I also accept that if the police had reached this conclusion, the options available to them to move Kim to another place for the night were limited.
It is clear from the evidence that Sgt McNevin, as the Officer in Charge of a small town police station, was very actively involved in community policing and he took a practical and caring approach to his duties. I accept that he would have acted more quickly, if he had understood there were significant concerns held by a nurse at Bridgetown Hospital for Kim’s health and safety, but in the context of what he knew of Kim’s history, and what information was communicated to him at the relevant time, there was no obvious urgency that required him to be recalled to duty.86
85 Exhibit 1, Tab 33, p. 7.
Superintendent Longhorn provided a report, and gave evidence, in relation to WA Police policy concerning welfare checks, given members of the public had raised concerns with police about Kim’s welfare in the days prior to his death.
Supt Longhorn advised that the Police Assistance Centre (PAC) provides the first point of contact for the Western Australian community seeking police assistance via ‘000’ (Triple Zero) and 131444. PAC Call Takers answering these calls are either sworn police officers or unsworn police staff and they use the WA Police Computer Aided Dispatch (CAD) system to create a task. They are guided by the PAC Knowledgebase manual as to how to then determine the type of incident (job type) and the level of urgency required (priority), which are both allocated to the CAD incident.
Calls received from the community surrounding the welfare/safety of an individual are allocated a specific job type, namely a Welfare Check (job type 48). The WA Police receive approximately 110,000 Welfare Check Incidents every year, which is the second highest incident type attended by WA Police. Welfare Checks run a close second to Disturbance Incidents for the highest number of police callouts.87 The priority of a Welfare Check will vary depending on the information conveyed, and can range from a Priority 1 (requiring urgent attention – a police response within 12 minutes) to Priority 4 (non-urgent – no prescribed time limit for a police response).88 Once created, a CAD incident is allocated to the State Operations Command Centre (SOCC), where it is dispatched to a suitable police (or other) resource.89
Supt Longhorn explained that, “[g]iven the infinite range of circumstances for which a welfare check may cover, there are no specific WA Police policies or guidelines prescribing police to respond in a particular way.”90 However, there are guidelines that require oversight of Welfare Check (48) CAD incidents, requiring that such incidents are not to be closed until the actions taken in response to the incident have been reviewed by a supervisor (Acting Sergeant rank or higher).91
In Kim’s case, a CAD incident was created on 28 November 2020 at 5.38 pm, which was determined to be a 48 Welfare Check and was allocated Dispatch Priority 3 (Routine response). The CAD incident was sent to the SOCC. A SOCC Radio Supervisor spoke with the Officer in Charge of Nannup Police Station (Senior Sergeant Allen McNevin), before the initial incident was cloned to a Priority 5 (NonUrgent) incident and then closed. The information that was entered indicated that the 87 Exhibit 1, Tab 35.
88 Exhibit 1, Tab 35.
89 Exhibit 1, Tab 35.
90 Exhibit 1, Tab 35 [17].
91 Exhibit 1, Tab 35.
[2025] WACOR 2 (S) Nannup OIC had stated that Kim was known to the police and it was not a police matter as requested, so the job was closed.92
Supt Longhorn expressed the opinion that, based upon the history of interactions between Nannup Police and Kim, the advice and information provided by Senior Sergeant McNevin “would appear appropriate in the circumstances.”93
Kim was an adult man with known medical conditions and a history of exposing himself to risk through his own decisions, but he was not known to have a mental illness and he generally did not engage in criminal behaviour. Supt Longhorn gave evidence that in his experience as a police officer of more than 30 years, police are receiving an increasing number of calls relating to elderly people who have absconded from either a hospital, care facility or even from home. Each case requires an individual assessment of risk and a judgment call to be made by the police involved. If it is simply a case of a missing person who needs to be found to ensure they have not come to harm, then that is an appropriate case for police to become involved to do a welfare check. However, there is an understandable reluctance on the part of WA Police to be involved in restraining elderly patients or forcing them to receive medical attention against their will, and I understand their general position that it is a community and health matter, not a police matter in such cases, noting that the involvement of police who are trained to use lethal force when required, can have tragic consequences for all involved.94
Supt Longhorn explained that in circumstances where police are called to attend to concerns for a person’s welfare, such as in Kim’s case, where he did not appear to have a mental illness under s 156 of the Mental Health Act 2014 (WA) and generally was understood to have capacity in relation to medical decisions, WA Police have limited powers available to intervene or direct such persons to attend hospital or other resources.95 There was nothing to suggest Kim was committing an offence and he was not in a public place or using public transport, so other options that might have been available to police, did not apply in this case. Superintendent Longhorn noted that while WA Police have access to community and government agencies who may be able to assist a person in Kim’s situation, he needed to have a desire to engage and accept such assistance. Supt Longhorn noted that Kim appeared to have had sufficient capacity to make his way home from Bridgetown to Nannup on his own and while there was an obvious risk in him doing so, it was a risk he chose voluntarily and there was nothing to indicate that it was a policing matter.96 As Supt Longhorn observed, Kim’s decision was probably “[n]ot a good decision, but we don’t police poor decisions.”97
If there had been information that Kim was at imminent risk of harm or death, then it may have been different, but given what was known, Supt Longhorn maintained that the options for police “to provide a meaningful or suitable outcome are extremely 92 Exhibit 1, Tab 35.
93 Exhibit 1, Tab 35 [24].
95 Exhibit 1, Tab 35.
96 T 135 – 136; Exhibit 1, Tab 35.
[2025] WACOR 2 (S) limited.”98 WA Police are in a difficult position as the MHA only provides for people with a psychiatric illness, which doesn’t appear to cover the increasing number of people with a cognitive impairment and associated behavioural issues, which leaves police in a difficult position. However, it is clear that experienced police officers like S/Sgt McNevin are willing to try to be practical and helpful in such cases, and as I indicated above, I am satisfied that if S/Sgt McNevin had understood the very real concerns held by at least Nurse Moyses in relation to Kim’s personal welfare, he would have investigated those concerns more quickly to see if there was an imminent risk to Kim’s safety and, if so, if there was anything he could do to help him and keep him safe.
I am also satisfied, based upon S/Sgt McNevin’s evidence, that the very real issues of an ageing population and homelessness in the South West of WA are understood by WA Police and active steps are being taken to try to ensure that local police respond in a caring but practical manner when dealing with people like Kim. S/Sgt McNevin indicated in his evidence that the percentage of the population that was over 80 years in Nannup at the time he left the role as OIC was at 69% and this is reflective of much of the South West. S/Sgt McNevin gave evidence the current District Superintendent for the region has formed an in-depth leadership programme in the district to try to and counsel and mentor officers coming into the role of Officer in Charge of the small regional towns in the area so that they “understand decisionmaking around community-based relationships and context to those that may well be unwell and living rough.”99
Noting the above, I make no adverse comments or findings in relation to the conduct of the police in this matter and I do not intend to make any recommendations in relation to WA Police arising out of the evidence in this inquest.
However, given the lack of services available, it was also difficult to identify good permanent options for Kim if he was to remain in the South West.
[2025] WACOR 2 (S) inpatient admission to the Perth metropolitan area. Dr Carrigan commented that the lack of a secure facility for people who have behavioural and psychological symptoms of dementia is very acute in the South West and Busselton Hospital has often borne the brunt of this issue, having to treat people on the acute medical ward with security staff support.101
Dr Carrigan explained that it is an ongoing problem as the WA South West region had the highest percentage of over 65’s per head of population in the entire country in the 2016 census, as it is a popular retirement destination.102 In Dr Carrigan’s opinion, a specific dementia care unit based in the South West, for example at Bunbury Hospital, would have been a safer environment for Kim as it would have been properly staffed with people who would have been able to manage his behavioural issues in a more expert fashion and likely provided an environment that was more conducive to him wanting to stay.103
In terms of other kinds of supported housing, such as a nursing home facility, Dr Carrigan commented that they are “pretty sparse”104 in the area. Dr Carrigan expressed support for the older persons’ initiative in the South West, comprised of social workers and nurses, who try to support older people to remain in their own homes for as long as possible. Dr Carrigan described it as “an invaluable service”105 that is under-resourced and adversely impacted by the large distances that staff are required to travel. Dr Carrigan suggested that a timely intervention by the service could have helped someone like Mr Vulich to stay out of hospital. The fact that Mr Vulich had been living in a caravan would not have been a barrier, as Dr Carrigan noted the staff “are well acquainted with dishevelled caravans, and various badly maintained locations.”106 However, given the strain on services, it is unclear how long that may have taken for the service to review him, if he had been referred.
Overall, Dr Carrigan expressed the view that there is a significant service gap for the abnormally large population of older people in the South West, with no proper facilities to treat them when their brains begin failing and they need comfortable ongoing management in a supportive facility that is not a hospital.107
Dr Hinton agreed with Dr Carrigan’s observations about the increasingly ageing population in the South West and the pressure it places on some of the older adult health services. He accepted that, as a result, some of the responsibilities fall to families, but the hospital staff still try to provide good support. Dr Hinton noted that in Kim’s case, his son clearly became overwhelmed fairly quickly, and in hindsight they would have done things differently in terms of keeping Kim’s son informed about what supports were there for him to try to manage his father’s care, as Kim became increasingly reluctant to stay in hospital, until a supported placement could be found. Dr Hinton also indicated that there was some confusion around what the
[2025] WACOR 2 (S) guardianship orders for Kim permitted, which could perhaps have been clarified with the Tribunal, for the benefit of Kim’s ongoing management. In addition, more information about Kim’s living conditions prior to going in to hospital would have been helpful, so that staff at Collie and Bridgetown Hospital could have gained a better understanding of the risks involved to Kim if he left hospital and returned home in his current state.108
Dr Hinton observed in his evidence at the inquest that the difficulty in this case was not in finding Kim a transitional hospital placement. The difficulty was retaining him there until they could find a place for him to live more permanently. He agreed with Dr Carrigan that if they had a more specific dementia ward to place him, that would likely have been a lot more successful. Alternatively, a nursing home environment that was secure would have been ideal. Instead, he went to a small country hospital that did not have the kind of staffing that allowed for managing patients with behavioural disturbances for long periods. Dr Hinton commented that where you have more of a nursing-home type setting with people who understand behavioural aberrations and are trained to de-escalate those situations, then “you get a very different outcome to being in a hospital.”109 However, those resources are not readily available in the South West and there is a high demand for what is available, noting the average age of medical admissions to Bunbury Hospital in more recent years is 74 years, which is reflective of a demographic shift towards an ageing population.110
Nurse Moyses, who is a very experienced nurse who has been working at Bridgetown Hospital since 2013, agreed with the comments of the doctors that there is a strain on geriatric aged care services due to an increasing number of older patients in the South West. Nurse Moyses noted that they don’t have enough nursing home beds in the region and Bridgetown Hospital is attached to a Joondalup nursing home for that service.111 In terms of the issues around Kim’s guardianship, Nurse Moyses commented that there is often difficulty obtaining copies of the relevant orders for a patient and they generally rely upon staff from the Social Work Department for guidance, but they generally only work weekdays and are not located in Bridgetown Hospital even when on shift on a weekend, which makes clarifying these issues difficult on weekends.112
However, even with these constraints, it is clear from the evidence that Nurse Moyses appreciated the risk to Kim at the time he left Bridgetown Hospital and she took some steps to try to prevent him leaving and, after he left, to get him back to hospital. Unfortunately, the attending doctor did not appear to appreciate Kim’s impaired level of functioning at that stage and didn’t take Nurse Moyses’ concerns seriously. Nurse Moyses gave evidence at the inquest that she was disappointed with Dr Morling’s response at the time as she had tried to explain to him her concerns that Kim lacked capacity and was possibly experiencing delirium. If he had agreed with her, she believes it is possible there might have been a different outcome as he could have been brought back to hospital and sent to Bunbury Hospital for further medical 108 Tn37 – 38.
[2025] WACOR 2 (S) investigations or until he returned to his baseline rational thinking. As Dr Morling was not able to be questioned, it is unclear why he took the view that he did, but it is clear that Nurse Moyses had done her best to convey to him her genuine concerns for Kim.113
Nurse Moyses commented at the inquest that she is disappointed at how things turned out and she still doesn’t know how Kim managed to get home to his caravan in Nannup, given his state at the time she last saw him. She wishes, in hindsight, that more had been done at the time he left the hospital on that last occasion, but she had done everything she could to raise the alarm as she understood very clearly that he was at risk of death in some way given the circumstances in which he walked out of the hospital. As Nurse Moyses noted, Kim was at immediate risk from exposure, collapsing from exhaustion or being run over on the highway, just to name a few things, as soon as he left the hospital, so she was extremely concerned for him and felt her concerns should have been taken more seriously by the doctor. Sadly, they were not and while those fears did not eventuate, Nurse Moyses’ fear that Kim would come to serious harm were proven right, just in a different form.114
The Senior Social Worker involved with Kim towards the end of his life, Ms Kelly, gave very clear evidence about the efforts being made by the social workers to try and assist Kim to find a secure and safe place to live. They were actively exploring funding and housing options and were in contact with Kim’s son and other practitioners to try to understand his financial position and the terms of his guardianship. However, there was some confusion amongst health staff as to what the orders meant, which resulted in a lack of clarity around the choices Kim was able to make for himself. Ms Kelly observed at the inquest that there is a process in WACHS for children at risk to have alerts entered on the health record to alert health workers that the child has been deemed a child at risk and it outlines their vulnerabilities. Ms Kelly suggested it would be helpful if the healthcare record for an adult with a guardianship or administration order in place could have a similar alert on the system, so it is clear to all involved that the person has some vulnerabilities and who needs to be included in decision-making when planning for the person. Ms Kelly commented that some of the communication issues that presented with Kim could have been resolved if such a flag had been in place for him.115
Ms Tiffanie Rushton, the Acting Director of Aged Care for WACHS, provided a detailed report and gave evidence at the inquest in relation to this matter. Ms Rushton addressed some specific issues raised by the Court, as well as providing a general overview of the current WACHS aged care services available in the South West.
There is an overlap between Federal and State services, as many aged care services are Commonwealth funded, but Ms Rushton was able to speak generally to these services in order to assist my understanding as to what was, and currently is, available to patients like Kim Vulich.116
116 T 85 – 86; Exhibit 1, Tab 36.
Ms Rushton explained that WACHS staff can apply to SAT for a guardianship order where they are concerned about capacity, and it seems that was done in this place by assisting the NOK to make the application.
Ms Rushton had sat through Ms Kelly’s evidence and she agreed that an alert on the digital medical records in cases like this, where there is a guardianship or administration order in place, might be a useful system improvement to arise out of this sad case. Ms Rushton agreed such an alert could assist frontline clinicians to provide better and safer care. Ms Rushton indicated that there is a working party in the WA South West who are working on health information management and they are best placed to consider how such an alert could best be included in the system as an improvement.117
Given there is currently a working party considering the implementation of this issue, I do not consider it necessary to make a recommendation in support of the proposal. I simply indicate my support, within the context of the evidence in this case that it may have assisted health staff to better understand what could and could not be done for Kim at the relevant time.
Ms Rushton also provided some information around WACHS DAMA procedure. Ms Rushton explained the process requires a screening of high, medium and low risk for that person, which would be undertaken by the clinical team in consultation with social work and the appropriate team, such as the older adult care coordination team.
Obviously, that depends upon the availability of those more central services, that are not based at an individual hospital, and Ms Rushton acknowledged there is not “luxury of time”118 in individual cases, but that is the intention of the policy.119 Ms Rushton noted that in this case, Kim did have a safety plan in place for such an eventuality. However, Ms Rushton agreed that there was some confusion around whether his right to refuse medical treatment included the right to discharge against medical advice, which would have benefitted from more clarity for the staff managing with him at the relevant time.120
Ms Rushton agreed in her evidence that guardianship and administration orders are poorly understood by people in general and frontline clinicians are not medico-legal experts, which can raise concerns about civil and criminality if they make the wrong decision. However, in Kim’s case, Ms Rushton expressed the view that the actions of the staff did not appear to have been impacted by the confusion, as he was not an involuntary patient, so there was nothing they could do to force him to stay when he indicated he intended to leave Bridgetown Hospital. His guardian was informed, as were police, and in Ms Rushton’s opinion, the actions of the staff were correct and aligned with the WACHS DAMA policy.121
Ms Rushton agreed that there is an increasing demand for aged care services in the South West and there is currently a specialist dementia care program being
121 T 93 – 94; Exhibit 1, Tab 36.
[2025] WACOR 2 (S) developed in Harvey to try to address some of that unmet demand. However, Ms Rushton indicated Kim would not have been eligible for that facility, even if it had existed at the time of his death. In terms of other residential care that might have been available for Kim, Ms Rushton observed that it was tenuous whether Kim would have been eligible for a bed in another facility, noting that at his age he would have had to go through more processes to get approval. There would have been the option of a private facility, but noting his financial and behavioural challenges, Ms Rushton considered it unlikely Kim would have been able to find a bed privately (noting these facilities have a long wait list and can pick and choose their clients).122
In terms of general bed availability, Ms Rushton explained that residential nursing facility beds across the board are at about 98% capacity and the remaining 2% are not vacant beds, but rather reflect the movement of residents. Ms Rushton indicated there is an absolute shortage of beds at a national level, and in that context, Kim would not have been a high priority for a residential facility as he was still relatively mobile and he would not attract the level of Commonwealth funding that would make him a priority patient for a facility. Ms Rushton explained there are some residential beds in very small facilities in some of the regional towns, including Bridgetown, but given the relatively low staffing levels at those facilities, Kim was unlikely to have been suitable for admission at one of those. This information explains the difficulties that Kim’s son and the WACHS staff were facing trying to get Kim somewhere to live outside the hospital.123
Ms Rushton indicated that if there had been more time, there could have been funding obtained for Kim to receive home care packages at his caravan. This could have been facilitated by the Older Adult Care Coordination team (also referred to as the Older Patient Initiative), which was established in October 2019 with a focus on elder abuse cases, but in 2020 expanded its focus to include referrals for other safety risk concerns that were not being managed by traditional responses, to act as a ‘safety net’ for these cases. The OACC team complements the Older Adult Mental Health program, as eligible clients often lack insight into their vulnerabilities due to diagnosed or undiagnosed mental health conditions or cognitive impairment. The staff can assist with connecting their clients with services such as housing, accessing a telephone or transport, which are not always easy to find in regional WA. Due to the complexity of the cases, they often require significant contact and Ms Rushton advised in her report that clients are supported by the OACC for an average of 78 days from referral until discharge.124
Ms Rushton noted the OACC is unique within WA Health and was born of an identified need for coordination and advocacy for individuals, many who are similar to Kim in that they are otherwise lost to follow up or ‘fall through the cracks’. The OACC service is currently funded by WACHS South West within its operational budget but the way it is funded relates to a service model that does not reflect the intensive case management that the service performs for their complex clients. Ms Rushton indicated that ideally the OACC would accept referrals from outside WACHS, such as direct from GP’s, noting that it performs a very useful ‘hospital
124 Exhibit 1, Tab 36.
[2025] WACOR 2 (S) avoidance’ pathway, but currently the service is too strained to open itself up to external referrals. The funding shortfall is currently being made up by WACHS due to the value of the service, but it requires an appropriate funding stream to continue and, hopefully, expand.125
RECOMMENDATION I recommend that the Honourable Minister for Health give active consideration to funding the WACHS to continue and expand the Older Adult Care Coordination Team in the S outh West in order to ensure that the needs of the v ulnerable members of the increasingly ageing population in the region are identified and met, to hopefully avoid another tragic death like that of Kim Vulich.
The evidence before me indicates that although health staff and police were aware generally of Kim’s situation, and there were concerns for his safety, there were limited options available to them to prevent Kim from returning to an unsafe living environment without his cooperation. Given his fluctuating mental state, it was difficult to reason with him, but he was not so unwell that he could be found to not have the capacity to make those decisions.
[2025] WACOR 2 (S) S H Linton Deputy State Coroner 12 February 2025
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