Deceased
Benjamin Jacob VAN TRIGT
Demographics
38y, male
Coroner
Acting State Coroner Linton
Date of death
2022-11-17
Finding date
2025-01-23
Cause of death
electrical injury
AI-generated summary
Benjamin Van Trigt, a 38-year-old man with schizoaffective disorder, died by electrocution at home on 17 November 2022 while on a Community Treatment Order (CTO). He had experienced multiple psychiatric relapses requiring hospitalization, with the most recent admission ending 4 October 2022. Despite regular community mental health follow-up including depot antipsychotic medication, weekly appointments, and crisis pathway education, Benjamin died by self-inflicted electrical injury. He reported suicidal ideation without specific intent on 26 October 2022 but did not access crisis services before his death. The coroner found his psychiatric treatment, supervision and care reasonable and appropriate, with no preventable failures identified. Benjamin's social isolation, concerns about losing his driver's license and employment, and possible rumination on pending court proceedings may have contributed to his deterioration, but suicide risk prediction remains notoriously difficult even with regular monitoring.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
[2025] WACOR 6 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER HEARD : 4 DECEMBER 2024 DELIVERED : 23 JANUARY 2025 FILE NO/S : CORC 3241 of 2022
DECEASED : VAN TRIGT, BENJAMIN JACOB Catchwords: Nil Legislation: Mental Health Act 2014 (WA) Counsel Appearing: Ms S Markham assisted the Deputy State Coroner.
Mr C Madondo (SSO) represented the North Metropolitan Health Service.
Case(s) referred to in decision(s): Nil
[2025] WACOR 6 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the death of Benjamin Jacob VAN TRIGT with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, Perth, on 4 December 2024, find that the identity of the deceased person was Benjamin Jacob VAN TRIGT and that death occurred on or about 17 November 2022 at 47 Coachwood Way, Maddington, from electrical injury in the following circumstances:
Benjamin Van Trigt, who was referred to as Benjamin at the inquest at the request of his mother, was a 38 year old man who died at his home on or about 17 November 2022 from a self-inflicted electrical injury. Benjamin had a history of schizoaffective disorder and was on an active Community Treatment Order (CTO) at the time of his death. By virtue of being on a CTO, Benjamin was an involuntary patient at the time of his death and his death came within the definition of a ‘person held in care’ under the Coroners Act 1996 (WA). Accordingly, a coronial inquest into his death is mandatory.
I held an inquest on 4 December 2024. Following this inquest, I am required to comment on the quality of the treatment, supervision and care provided to Benjamin while on the CTO prior to his death.1
Benjamin was described by his mother as a wonderful young man whose adult life was, unfortunately, adversely affected by drug use.2 Benjamin went through a lot of health issues as a child, including three operations on his bladder as he was diagnosed with bladder reflux when he was born, and for the rest of his life he had one good kidney and one poor kidney. Later, he found out he had Von Willebrand’s disease, a bleeding disorder. He was also reported to have been diagnosed with ADHD as a child and was prescribed stimulant medication.3
Benjamin had been a quiet, intelligent teenager who enjoyed playing netball, but after rupturing his ACL when he was 16 years of age and then being diagnosed with Von Willebrand’s disease, he started to become depressed and began to selfmedicate with cannabis. Benjamin’s family had a history of depressive illness and bipolar disorder, and his mother was aware that cannabis could worsen his depressive symptoms and cause other mental health issues. She tried to warn her son about the risks for him, but unfortunately, he did not heed her warnings.4
He developed psychosis at the age of 19 years associated with his substance use. In the lead-up to his first diagnosis, Benjamin had apparently attempted to strangle himself with a cord. He was admitted to the Armadale Mental Health Service (AMHS) Mental Health Unit and was diagnosed with psychosis, probably secondary to substance use (THC/cannabis and amphetamines).5
Following this first admission, Benjamin was seen, on and off, as an outpatient by Armadale Health Service Community Services in 2003 and 2005. He found some peace and solace in the Baptist Church and became a youth leader. He seems to have been relatively well for quite some time, before he relapsed in 2015.6 He then spent 1 Sections 22(1)(a) and 25(3) Coroners Act 1996 (WA).
2 Exhibit 1, Tab 21.
3 Exhibit 1, Tab 17.1 and Tab 21.
4 Exhibit 1, Tab 21.
5 Exhibit 1, Tab 17.1.
6 Exhibit 1, Tab 21.
[2025] WACOR 6 some time in NSW over the period of 2015 to 2016, where he was reportedly admitted to hospital on two occasions for a drug-induced psychotic illness, with a possible secondary diagnosis of Bipolar Affective Disorder, although this was never confirmed. Benjamin was placed on depot antipsychotic medication. He was said to have responded well to the medication and had only residual psychotic symptoms.
He later returned to Perth. Benjamin was last seen by AHS community staff in 2016.7
He then reportedly discontinued his depot medication but managed to continue living in the Perth community without any further hospital admissions until 2022. He enrolled in a Chemistry degree at Curtin University and did two years before he decided it was too much pressure. He then found work as a dog washer, a job that he seems to have enjoyed as he preferred to interact with dogs rather than people. He lived in a house owned by his mother at this time.8
Medical records indicate that in about December 2021, his mental health began to decline significantly. He engaged in bizarre behaviour, such as putting whiteboards with messages around the outside of his house and he had not been taking good care of his pet chickens, which was unlike him.9
He eventually deteriorated to the point that he required two admissions to the AMHS Mental Health Unit from 30 August to 20 September 2022 and then again from 25 September to 4 October 2022.10
On the first occasion, he was brought in by ambulance on the evening of 27 August 2022, following a high-speed motor vehicle crash and with a report he had been in conflict with another driver. The reports suggest he had deliberately rammed his dog wash van into another vehicle as he believed the other driver was ‘bullying’ other motorists. His behaviour on apprehension had caused the police to suspect he was experiencing mental health issues and he also had some facial injuries that required treatment. Benjamin was later charged with reckless driving and bailed to appear in court on 22 November 2022.11
Benjamin had also been charged and released on bail that morning in relation to another incident that occurred in Kings Park earlier that same day, where he was alleged to have assaulted several people and stolen a mobile telephone. His behaviour during both incidents suggested he was experiencing deteriorating mental health.12
Benjamin reportedly became very agitated in the ambulance on the way to hospital.
On presentation at the Emergency Department on the evening of 27 August 2022, Benjamin was noted to be psychotic. He appeared agitated and was responding to unseen stimuli. His blood samples were positive for THC and a ‘black gummy substance’ in an aluminium foil package was later found in his possession. He tried 7 Exhibit 1, Tab 13 and Tab 17.1.
8 Exhibit 1, Tab 17.1 and Tab 20.
9 Exhibit 1, Tab 15.
10 Exhibit 1, Tab 17.1.
11 Exhibit 1, Tab 14, Tab 15 and Tab 17.1.
12 Exhibit 1, Tab 14 and Tab 17.1.
[2025] WACOR 6 to abscond from the hospital, charging at a door and breaking the glass before he could be restrained. Benjamin was assessed and no significant injuries were noted, either from the car crash or the door incident, so the focus shifted to his psychiatric care.
Benjamin was admitted to the Psychiatric Unit of Armadale Hospital on 30 August 2022 as an involuntary patient. He was commenced on the oral antipsychotic medications zuclopenthixol, paliperidone and olanzapine. He initially required a 2:1 security special due to his high risk of verbal and physical aggression. His psychotic symptoms were slow to resolve so he was changed to a paliperidone depot on 7 September 2022 and a mood stabiliser, sodium valproate, was added. He still had periods of verbal and physical aggression and had altercations with other patients, as well as displaying inappropriate behaviour towards staff at times, but Benjamin’s mental state and behaviour was reported to have eventually improved on this antipsychotic medication and mood stabiliser.
His principal diagnosis during this admission was schizoaffective disorder (major psychotic illness with mood features), along with features of personality disorders (antisocial and narcissistic). As part of discharge planning, Benjamin agreed to be compliant with his medication if released into the community and stated he did not need a CTO to ensure his compliance. A consultant psychiatrist assessed Benjamin and determined he had gained mental stability and was no longer responding to unseen stimuli. His risk to himself or others was assessed as low by this stage.13
On 19 September 2022 his involuntary patient status was revoked and he was discharged on 20 September 2022 on the depot medication (paliperidone) with follow up by the community mental health team.14 It was also planned that he would be linked in with alcohol and drug services through the community mental health team, as it was important for his mental stability that he refrain from using substances and he needed help to cease cannabis use. It was acknowledged that a CTO may be needed if Benjamin’s willingness to engage with services changed, but at the time of this discharge he seemed agreeable to doing so voluntarily.15
Benjamin was also put in contact with the Mental Health Law Centre to assist him with his pending charges.16
It seems his psychiatric team were hopeful Benjamin would be able to manage on his own, but he was very isolated in the community. Benjamin’s mother helped him with a place to live, but she has another son with high care needs, so she could not live with him. She indicated at the inquest that she was worried about him being discharged to live in a house on his own. It seems she was right, and it is clear Benjamin struggled to cope once discharged.17 13 Exhibit 1, Tab 15.
14 Exhibit 1, Tab 17.1.
15 Exhibit 1, Tab 15.
16 Exhibit 1, Tab 19.
17 Exhibit 1, Tab 21.
Benjamin self-presented to Armadale Hospital ED two days later on 22 September 2022, reporting feelings of paranoia. He said he did not feel safe at home and requested to be admitted. He required sedation by ED staff prior to being psychiatrically assessed. Benjamin reported he had not filled the prescription for his mood stabiliser and admitted he had drunk alcohol and consumed cannabis. He was given a short supply of his mood stabiliser medication and then discharged home for follow-up in the community, as previously planned.18
Two days later, on 24 September 2022, Benjamin’s neighbours called police after he behaved in an aggressive and threatening manner towards them, including damaging a fence. Benjamin left the scene in his car, but then returned while police were present talking to the neighbour. It was immediately apparent to the attending police officers that Benjamin required a mental health assessment, so he was detained under the Mental Health Act 2014 and taken to hospital. The neighbour told police he did not want to provide a statement, so initial charges were withdrawn and it was solely treated as a mental health episode.19
At the time of admission, he expressed paranoid thoughts, accusing his neighbours of stalking him and stealing his identity. He was again found to be psychotic and was considered to present a risk to himself and others, so he was admitted involuntarily.
His diagnosis was again schizoaffective disorder. A urine drug screen was negative.
His dose of sodium valproate was increased and oral paliperidone was added and he appeared to settle. He was treated for just over a week, before being discharged again on 4 October 2022. At the time of discharge, he reported feeling safe and well and denied any risk to himself or others.20
19 Exhibit 1, Tab 14.2.
20 Exhibit 1, Tab 17.1.
21 T 45, 48; Exhibit 1, Tab 17.2.
[2025] WACOR 6 mother was noted to be his only family support. The Mental Health Law Centre was helping him with his legal difficulties that had arisen in the context of his mental health relapse, so it was hoped this would be resolved satisfactorily.22
Benjamin was seen by Mr Masterman for the first time on 10 October 2022, at which time he was well groomed and behaving appropriately. He denied taking any illicit substances or alcohol use and reported he had not experienced any perceptual disturbances. He was still renting off his mother and had borrowed a van so he could keep dog washing while his van was being repaired. His mood was self-rated as 7/10.
He was amenable to treatment and denied being a risk to himself or others. Benjamin had a treatment, support and discharge plan that had been prepared while he was still on the hospital ward, so the plan was to work towards preparing a more community based care, treatment, support and discharge plan in the future.23
They spoke on the phone again a few days later, on 13 October 2022. Benjamin seemed to be managing well and again denied any deterioration in his mental health or risk concerns. He reported a healthy sleep pattern and a stable mood. They discussed the timing of his depot injection, to make sure it could accommodate his work commitments.24
Benjamin spoke to Mr Masterman on the phone again on 26 October 2022. Benjamin reported things had been ‘up and down’ and he indicated he had experienced thoughts of suicide, but without plan or intent. He said he did not think he was needed and did not think there was much hope for the future. He specifically seemed worried about his finances if he lost his driver’s licence. Mr Masterman suggested he should consider applying for an extraordinary driver’s licence so he could still work.
This suggestion appeared to have brightened Benjamin’s mood and he seemed eager to look into it further. They re-confirmed crisis pathways before ending the call.25
23 T 26; Exhibit 1, Tab 20 and Tab 23.
24 Exhibit 1, Tab 20 and Tab 23.
25 T 28 - 31; Exhibit 1, Tab 20 and Tab 23.
26 T 6 – 9; Exhibit 1, Tab 22.
Dr Ayeni had not seen Benjamin before, but he was aware that he was on a CTO as he had been informed by Dr Dell in a telephone conversation that Benjamin was coming to the clinic as a patient on a CTO and Dr Ayeni would be allocated as Benjamin’s supervising psychiatrist. Dr Ayeni completed a comprehensive Psychiatric Review at this first appointment. This included taking a personal history directly from Benjamin, although he also had access to Benjamin’s documented recent psychiatric history and Mr Masterman was also there to assist with information already obtained. Dr Ayeni gave evidence that his goal when meeting a patient for the first time is “to assess his mental state, establish that he’s able to engage on the CTO, clarify his capacity to make a treatment decision, look into issues about medication if required, and [look] if there are … indications for us to revoke the CTO, either by saying the person is now voluntary or the person needs to go back to the hospital.”27
Dr Ayeni explained that his usual practice is to start with asking a patient, “How can I help you today?”28 When he asked Benjamin this question, Benjamin replied that he wanted Dr Ayeni to “psychoanalyse”29 him. Dr Ayeni understood that his request was really for Dr Ayeni to assess his mental illness and explain what had been happening to him. Obtaining his history, from Benjamin’s perspective, helped in that process.30
Benjamin appeared willing to engage and spoke extensively about what had been happening for him. Dr Ayeni took detailed notes of their conversation. Benjamin was open about hearing voices when he was experiencing psychosis and committed the offences. He indicated the intensity of those voices had since reduced significantly.
Dr Ayeni considered the description of events was consistent with Benjamin having been very unwell and having psychotic symptoms at the time, but as his antipsychotic medication had begun to take effect, he now had some insight. They also talked about Benjamin’s current charges and what he planned to do about them.
Dr Ayeni’s impression was that Benjamin was genuinely remorseful about his conduct that had occurred while he was unwell, and with the guidance of his lawyer, indicated he planned to plead guilty and get them resolved. He seemed optimistic about the outcome, although he was still a little worried about the consequences that might flow. He told Dr Ayeni he hoped to be able to get back to work, and Dr Ayeni formed the impression work was a significant protective factor for Benjamin.31
29 Exhibit 1, Tab 22 [16].
30 T 9 – 11; Exhibit 1, Tab 22.
31 T 12 – 13, 20; Exhibit 1, Tab 17.1, Tab 20 and Tab 22.
[2025] WACOR 6 Benjamin was also reported to have some residual psychotic symptoms, despite being on his depot medication, so it was important to ensure he did not relapse.
Benjamin said he was willing to take his medication and engage with his treating team, but Dr Ayeni considered it was appropriate to extend the intensive treatment phase of the CTO and for Benjamin to receive weekly follow-up, support and monitoring of his mental state until he saw Dr Ayeni again. Dr Ayeni arranged the next appointment for 23 November 2022, following his court appearance the day before, so that he could be given extra support if he needed, depending on the outcome of the court case.32
Mr Masterman spoke to Benjamin on the phone again on 3 November 2022 and they arranged another appointment for 9 November 2022. He denied any risk concerns and seemed normal during the call.33
Benjamin was seen again at the Clinic on 8 November 2022 and given his depot medication by a registered nurse. Although he was there just to receive his medication, as per usual practice at the clinic, the nurse took the opportunity to conduct a brief risk assessment. Benjamin was noted to be well kempt with tidy attire and he seemed calm, alert and orientated to time and place. He reported his mood was ‘fine’ and he denied any suicidal ideation on direct questioning and said he felt safe. He was not considered to be a risk to himself at the time of assessment and no psychotic symptoms were observed by the Clinic nurse who administered the injection.34
The planned appointment with Mr Masterman on 9 November 2022 didn’t occur, but another appointment was arranged for Thursday, 17 November 2022. This was the last time Benjamin was in contact with anyone at the Clinic. He was seen on this date at the Clinic for review by Mr Masterman. Benjamin stated he had only recently started his antidepressant medication (fluoxetine) due to an ID issue at his pharmacy.
His mood was described as ‘alright’ at 5/10 and he seemed concerned that he was not feeling any positive effect from the antidepressant. Mr Masterman reminded him of the timeframe of 6 to 8 weeks for antidepressants to take effect and he seemed encouraged by this information. Benjamin denied any alcohol use but reported some minimal daily cannabis use. He was reminded of the impact this could have on his mood and the need to work towards cessation rather than just reduction. He was still working as a dog washer but said he was no longer enjoying the job as much as he used to and reported generally low mood. Mr Masterman made suggestions about meaningful activity Benjamin could engage in, such as walking and running groups, and other ways to find groups who enjoyed similar activities were also discussed.
Once again, he denied any risk to himself or others when questioned and he was reminded of the crisis pathways. Benjamin said he would make contact if there was any escalation in his low mood or suicidal ideation. His next planned review date was 17 February 2023.35 32 T 14 – 16, 19; Exhibit 1, Tab 17.1, Tab 20 and Tab 22.
33 Exhibit 1, Tab 23.
34 Exhibit 1, Tab 17.1 and Tab 20.
35 T 32 - 33; Exhibit 1, Tab 13.2, Tab 17.1, Tab 20 and Tab 23.
At that time, he had told her he was afraid he was going to lose his licence due to demerit points and go to jail as a result of the incident in Kings Park. He returned home and his mother visited him at his house later that afternoon. He seemed calm and happy at that time.36
On 19 November 2022, Benjamin did not answer the door when his mother went to his home to see him, although both vans were parked in the driveway. He also did not answer his phone when she then tried to call him. She eventually left as she thought he must be sleeping and didn’t want to disturb him. She came back to the house a bit later, after still being unable to contact him, but nobody answered, so she left again.37
Benjamin’s mother returned to his house the following day, being 20 November 2022, and this time she had brought his spare key with her. She used the spare key to enter his house. She found her son, obviously deceased, lying under a blanket on a mattress in the loungeroom. She called St John Ambulance (SJA) at 11.45 am and reported what she had found. SJA officers arrived just before noon and confirmed that Benjamin had died some time earlier.38
SJA had notified the WA Police and police officers attended the house at 12.35 pm.
They observed Benjamin’s body was in an advanced state of decomposition. When they removed the blanket, the police officers immediately heard a buzzing noise and simultaneously observed smoke, which was increasing in intensity. They realised Benjamin had a live electrical cable, with the ends cut, in his mouth. The police officers immediately left the house and turned off the mains power, to ensure the safety of all in attendance. Western Power then attended and rendered the house safe to enter.39
37 Exhibit 1, Tab 13.
38 Exhibit 1, Tab 2 and Tab 21.
39 Exhibit 1, Tab 2 and Tab 3.
40 Exhibit 1, Tab 2.
An external post mortem examination, including a CT scan, was performed on 25 November 2022 by Forensic Pathologists, Dr Cooke and Dr Patton. They observed post mortem decomposition changes and electrothermal injury to the face, chest, left upper arm and right hand. The CT scan showed no evidence of internal injury or features of natural disease.42
Toxicology analysis showed the presence of high levels of alcohol and cannabis, consistent with recent use. The medication fluoxetine and its metabolite were also detected. Benjamin’s depot medication, paliperidone, was not detected, but I am advised that low therapeutic levels of this drug may not be detected in the toxicology screening performed by the Chemistry Centre. His other medication, the mood stabiliser sodium valproate, is not covered in routine screening.43
At the conclusion of their limited investigations, Dr Cooke and Dr Patton formed the opinion the cause of death was electrical injury. I accept and adopt their opinion as to the cause and manner of death.44
Benjamin was a 38 year old man with a long history of mental health concerns. He had sporadic contact with mental health services over the years and had a longstanding diagnosis of schizoaffective disorder, which was negatively affected by his cannabis use. When unwell, he experienced grandiose ideas that put him at risk and sometimes led to negative contact with others.
Benjamin was last discharged from hospital on 4 October 2022. He was placed on a CTO to ensure that he remained on his antipsychotic medication and was monitored in the community, as he had quickly relapsed when discharged from hospital not long before. While under the CTO, and in the lead up to his death, Benjamin had regular mental health follow up and received his depot medication as scheduled. He reported that he had thoughts of self-harm and feeling hopeless about the future, without any specific intent or plan. He was reminded of crisis pathways, should he begin to feel actively suicidal, but it appears that he did not access those services prior to his death.
Dr Ayeni observed in his evidence that it is notoriously difficult to predict those people with suicidal thoughts who will actually complete the act, but what “usually 41 Exhibit 1, Tab 21.
42 Exhibit 1, Tab 6.
43 Exhibit 1, Tab 6 and Tab 7.
44 Exhibit 1, Tab 6.
[2025] WACOR 6 helps with identification of suicide is helplessness and hopelessness.”45 At the time he assessed him, he had not seen any sign Benjamin was feeling either of these two emotions. However, in hindsight it appears that Benjamin may have begun to experience feelings of hopelessness around the possibility of losing his licence and being unable to work, although he chose not to share those thoughts with those around him.46 Dr Ayeni also observed that these kinds of thoughts can be fluctuating, so it is possible he did not share these thoughts because they came at times when he was on his own, noting he lived alone.47
Mr Masterman, who had the more continuous and recent contact with Benjamin before his death, was also asked about his reflections on Benjamin’s care, knowing the sad outcome. Mr Masterman felt that perhaps the issue of his medication could have been solved by providing an immediate supply of his antidepressant, which might have improved his mood earlier, but otherwise generally felt that all appropriate efforts had been made to provide Benjamin with comprehensive support and care. Mr Masterman agreed that it might have helped to have Benjamin’s family included more, but that the level of family involvement is dependent on the client’s willingness to allow family members to be kept informed. In this case, Mr Masterman recalled that Benjamin seemed to want to focus on doing things autonomously, without relying upon his family. He did seem socially isolated, so Mr Masterman encouraged him to look within the community for groups where he might be able to find people with similar interests, even if it was just a community walking group, but it had to be self-initiated for it to work and Benjamin was still contemplating it in those early stages.48
Dr Ayeni indicated that he had reflected on Benjamin’s care and whether there were things that could have been done differently to try to keep Benjamin safe, but felt that the appropriate decisions were made at the time within the framework of the need to promote Benjamin’s autonomy while living with a mental illness. If he had been aware that Benjamin had become acutely suicidal, it would have been within Dr Ayeni’s power to revoke the CTO and return Benjamin to hospital as an involuntary patient, but based upon what the treating team knew at the time, there was no proper basis to take that significant step.49
Dr Dell, who had treated Benjamin during his last admission, reviewed the records of his treatment while on the CTO and, while acknowledging the tragedy of Benjamin’s death, expressed the opinion Benjamin received an acceptable standard of service while on the order.50 Dr Dell agreed with the evidence of Dr Ayeni that unfortunately, many people have suicidal thoughts but only a small percentage of them complete suicide and there are no tools that reliably predict who will go on to complete the act.51 Dr Dell gave evidence that in her experience the actual attempt is
50 Exhibit 1, Tab 17.
[2025] WACOR 6 often quite impulsive, and the intention to act can actually happen over a couple of hours, if not briefer time period, so it makes it hard to know when it might occur.52
I am satisfied that Benjamin’s psychiatric treatment, care and supervision leading up to his death was reasonable and appropriate. I consider it was appropriate for him to be released from hospital on a CTO, and I note that he was being given intensive support over a prolonged period as it had been identified that he was at risk of being non-compliant with the conditions and he might then harm himself or harm others if he was not engaging with his treatment plan. Benjamin was aware of the ways he could seek help when feeling suicidal or if his mental state deteriorated, and had done so in the past when becoming unwell.
It appears on the evidence that Benjamin may have been ruminating on the outcome of his court proceedings for offences that occurred when he was very unwell but which he might still have to suffer some life-affecting consequences. Unfortunately, it appears that when his mental state deteriorated this last time, he chose not to access that support. Instead, he executed a plan to harm himself at his home without telling his mother or his community mental health team. By the time Benjamin’s death was discovered, it was too late to help him.
Benjamin’s mother raised her concerns at the inquest about the lack of communication between her son’s community mental health team and herself prior to his death. She acknowledged that, as an adult, Benjamin was able to choose how involved she was in his medical care, but she felt that she had important information to provide, knowing that her son was not always able to give an accurate history given his illness. She is hopeful that a lesson can be learnt from this sad case for mental health practitioners to recognise that the parents of a child with a long history of mental illness should be asked for background information to ensure that they are working from a reliable history of events.53
Mr Masterman still works for AMHS, and is now the Senior Social Worker and Care Coordinator for the Orchard Avenue Community Mental Health Service in Armadale, which has replaced the Eudoria St Clinic.54 He indicated, along with Dr Dell, that family members are engaged with a client’s permission, and he agreed that this is an important part of comprehensive mental health care in the community.
53 Exhibit 1, Tab 21.
54 Exhibit 1, Tab 23.
55 Exhibit 1, Tab 21.
Unfortunately, Benjamin sometimes relapsed into psychosis and required intensive treatment in hospital. At those times, he would sometimes come into contact with the police due to aggressive behaviour and he was felt to also pose a risk to himself at those times. He would improve with medication and treatment, so noting the requirement to impose the least restrictive form of treatment, attempts had been made to allow Benjamin to manage his own care in the community on a voluntary basis prior to his death. When this failed, he was then made an involuntary patient, first in hospital and then in the community on a CTO. This allowed him to live at home but required him to engage with treatment and ensured a level of regular monitoring.
Despite being monitored quite closely on a CTO, and receiving his depot medication, Benjamin’s mental health declined in November 2022 and he took steps to end his life by way of electrocution. He left a note that did not really expand too much on his thoughts, but seems to suggest he had made a deliberate, considered decision to end his life, rather than being incapable of making that decision.
I find that Benjamin’s death occurred by way of suicide. As Benjamin’s mother eloquently put it, “he is now at peace and his demons have gone.”56
No recommendations arose out of the conduct of the inquest, and no adverse comments are made in relation to any of the people involved in Benjamin’s care. He was managed as well as possible, but sadly the people supporting him were not able to prevent his death.
S H Linton Deputy State Coroner 23 January 2025 56 Exhibit 1, Tab 21.
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