Inquest into the Death of Jalen Hunter NORRIS
Inquest into the Death of Jalen Hunter NORRIS
Delivered on : 6 March 2025
Delivered at : Perth
Finding of : Coroner Urquhart
Recommendations :N/A
Orders/Rules : N/A
Suppression Order : N/A
Summary : Shortly after 6.00 pm on 9 April 2021, Jalen Hunter Norris (hereafter referred to as Jalen at his family’s request) died from multiple injuries he sustained when he was struck by a train. He was 23 years old.
As Jalen had been in police custody immediately before his death, he was a “person held in care” and an inquest was mandatory pursuant to section 22(1)(a) of the Coroners Act 1996 (WA).
Earlier on 9 April 2021, Jalen had been arrested by police following an argument he had with his partner at his parents’ home. He was taken to Kiara Police Station where he was processed for two charges of damage and one charge of possession of cannabis. When he was in a cell, Jalen deliberately struck his head against the glass panel of the cell door. Police called for an ambulance and Jalen was taken to the ED at St John of God Midland Hospital (SJOGMH).
Although police served Jalen with his bail papers at SJOGMH, the prosecution notices for the three charges had not been formally lodged with the Magistrates Court. Consequently, Jalen had not been lawfully released to bail from police custody.
The triage nurse at the ED noted that Jalen had an “altered mental state” with “delusional comments” and was “paranoid about family”. Doctors at the ED assessed Jalen as having a “situational crisis” with no evidence of a depressive illness or psychotic phenomenon. Jalen denied he had thoughts of self-harm or suicide to ED doctors. As medical staff had concluded SJOGMH had no duty of care to prevent Jalen from leaving the ED, he was considered to be a voluntary patient. He was therefore permitted to leave at about 5.10 pm. Jalen then walked about 2 km to a train crossing where he sat down on the tracks in front of an oncoming train.
The Coroner was satisfied that Jalen was experiencing paranoid delusions when he was taken into police custody and found that police missed an opportunity to provide ED staff with comments Jalen had made during the serving of his bail papers. These comments regarded Jalen’s delusional belief his partner was going to be murdered by a gang and that his parents would be blamed if he died by suicide. Otherwise, the Coroner was satisfied with the supervision, treatment and care by police of Jalen.
The Coroner also identified an organisational missed opportunity by SJOGMH for not making a recommendation that Jalen have a mental health assessment by the ED’s Psychiatric Liaison Service.
The Coroner was satisfied with the changes that have been made since Jalen’s death to (i) the form completed by police when handing over a person in custody to an ED and (ii) procedures at SJOGMH which ensures patients attending the ED with mental health issues like Jalen’s, will have a mandated check of their on-line psychiatric records by a mental health nurse.
Catch Words : Mandatory Inquest : Supervision, treatment and care : Mental Health : Suicide
Last updated: 14 March 2025