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Coroner's Court of Western Australia

Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia

Inquest Findings

Home →Inquest Findings→Inquest Findings 2026→Di Biase, Andre Josef and Dodd, Bryan Jeffrey

Inquest into the Deaths of Di Biase, Andre Josef and Dodd, Bryan Jeffrey

Delivered on :   2 October 2026

Delivered at : Perth

Finding of : Coroner Hartley

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary :

In May 2023 Mr Di Biase was being treated as an involuntary mental health patient in the Mental Health Unit (MHU) located on the ground floor at Royal Perth Hospital (RPH). He became physically unwell and was transferred Ward 9A, on level 9 of the A Block building, for treatment of severe bacterial tonsilitis with intravenous antibiotics.

On 8 May 2023, Mr Di Biase banged on the outward facing window of his room until he broke the glass. He then climbed through the broken window onto the balcony area and plunged to his death over the balcony railing.

In September 2023 Mr Dodd was being treated on Ward 9A for pain and delirium associated with end stage cancer.

In the evening on 13 September 2023 Mr Dodd broke the outward facing window of his room and escaped onto the balcony where he fell to his death.

The coroner was satisfied that the clinical decisions made in relation to both men were appropriate when viewed in light of the information available to their treating teams at the time.

The coroner found that the deaths of Mr Di Biase and Mr Dodd occurred in strikingly similar circumstances within a period of only four months. Both men were vulnerable patients being treated on Ward 9A at RPH. Both were able to break the annealed glass window in their room, gain access to the balcony and jump or fall to their deaths.

While their underlying medical and psychiatric conditions were very different, the common factor in both deaths was the existence of an environmental hazard in the form of the annealed glass windows.

The East Metropolitan Health Service has made numerous changes as a result of the deaths.

Catch Words :   Mandatory Inquest : Death in care :  Discretionary Inquest: Joint Inquest: Mental Health :Suicide


Last updated: 15 October 2026

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