Inquest into the death of Jaxon Charles Kinnane
Delivered on : 6 December 2024
Delivered at : Perth
Finding of : Coroner Urquhart
Recommendations :Yes
In order to potentially improve the effective management of prisoners with serious mental health conditions, the Office of the Chief Psychiatrist undertakes an assessment of the use of Community Treatment Orders within the prison setting.
Orders/Rules : N/A
Suppression Order : N/A
Summary : On 13 October 2020, Jaxon Charles Kinnane (hereafter referred to as Jaxon at his family’s request) was found submerged in the waters of the Swan River in Caversham. His cause of death was immersion in water (drowning) in a man with combined drug effect. Jaxon was 22 years old.
Jaxon’s death was a reportable death under the Coroners Act 1996 (WA) (the Act) as it was unexpected, but an inquest was not mandatory under section 22(1) of the Act. However, after receiving written submissions from Jaxon’s family, the State Coroner determined that an inquest was desirable under section 22(2) of the Act in order to examine the medical treatment and care Jaxon received for his mental health in the lead up to his death.
Jaxon had a complex mental health history. He had been diagnosed with various conditions including ADHD, PTSD, drug-induced psychosis, delusional disorder and schizophrenia. His treatment was complicated by his long-held lack of insight regarding his mental health and his refusal to voluntarily take antipsychotic depot injections.
From 22 March 2020, Jaxon was remanded in custody – first in Hakea Prison and then in Casuarina Prison (Casuarina) from 18 April 2020. Throughout his time in prison Jaxon complained of a microchip in his ear which was conveying messages to him. Although he had obvious psychosis, Jaxon refused to take any antipsychotic medication. As a result, he had two admissions to the State Forensic Unit at Graylands Hospital (the Frankland Centre). During the second admission he was involuntarily given depot injections of paliperidone (an antipsychotic medication) which appeared to stabilise his psychosis. However, after Jaxon was discharged back to Casuarina on 4 August 2020, he refused his next depot injection on 26 August 2020. Within days, his mental health began to deteriorate and he refused to also take his oral antipsychotic medication.
At a court appearance on 8 September 2020, Jaxon pleaded guilty to a number of offences for which he received fines. This meant he was released from custody that day, a development that mental health staff at Casuarina had not expected.
On 9 September 2020, Jaxon voluntarily presented to St John of God Midland Hospital (SJOGMH) with suicidal ideation. He was subsequently admitted to the Mental Health Unit at SJOGMH as a voluntary patient following a psychiatric review. Jaxon was later diagnosed with a relapse of symptoms of schizophrenia.
For the duration of his stay at SJOGMH, Jaxon was prescribed oral antipsychotic, antidepressant and antianxiety medications, which he agreed to take. However, his psychosis regarding the microchip in his ear remained unresolved.
At lunchtime on 9 October 2020, Jaxon was granted unescorted leave from SJOGMH and was due to return at 4.00 pm. He did not return at that time and his last known communications were texts with father and sister on the morning of 10 October 2020 and a telephone conversation with a friend on that day.
The Coroner was satisfied that the supervision, treatment and care Jaxon received at Casuarina and the Frankland Centre for his mental health was appropriate, given the resources available to mental health service providers at those two sites.
Despite some missed opportunities identified by the Coroner, he was also satisfied that the supervision, treatment and care Jaxon received at SJOGMH for his mental health was appropriate.
The Coroner remained concerned regarding the resources available to treat prisoners with acute mental health conditions and made one recommendation that addressed the potential use of Community Treatment Orders within a prison setting. The Coroner also endorsed the three recommendations made by the Court in an inquest finding earlier in the year that dealt with the care and treatment of mentally unwell prisoners.
Catch Words : Discretionary Inquest : Mental Health : Supervision, Treatment and Care : Community Treatment Orders : Prison Mental Health : Open Finding as to Manner of Death
Last updated: 13 December 2024