Inquest into the Death of Karl Albert STEINHAUSER
Inquest into the Death of Karl Albert STEINHAUSER
Delivered on : 23 December 2025
Delivered at : Perth
Finding of : Coroner Urquhart
Recommendations : Yes
Recommendation No. 1
In order to provide appropriate treatment to acutely unwell mental health patients in the Goldfields region without the need to transfer them to Perth for their treatment, the Court remains committed in its support for the construction of a purpose-built mental health facility at the Kalgoorlie Health Campus and recommends it be undertaken as soon as possible.
Recommendation No. 2
To improve the transfer of rural mental health patients to metropolitan hospitals and for the reasons outlined in Appendix 7 of the Statewide Mental Health Bed Access, Capacity and Escalation Policy 2025 (Version 1.2, released in July 2025) (the Policy), a working group be established that is co-led by WACHS and the Department of Health State Health Operations Centre, with input from the Mental Health Commission and the Office of the Chief Psychiatrist and other relevant stakeholders. The purpose of the working group is to ensure processes are in place to support the implementation of the Policy, particularly the referral and transfer practices, including a fast-track trial prioritisation process, of rural and regional mental health patients to metropolitan hospitals.
Recommendation No. 3
The Department of Health, in collaboration with relevant stakeholders across the State’s health system, develops a system level process that provides oversight for the quality of care of interhospital transfers of mental health patients from rural and regional areas who are under the Mental Health Act 2014 (WA). This should include regularly reporting the numbers and modality of transfer by site (whether intubated or sedated), any morbidity or mortality related to transfer (inclusive of effects of intubation/sedation) subsequently detected, and whether the underlying reason for transfer relates to considerations such as a lack of specialised mental health infrastructure at the referring site.
Orders/Rules : N/A
Suppression Order : N/A
Summary : On 12 March 2023, Karl Albert Steinhauser (Kyle), died at Fiona Stanley Hospital (FSH) from pulmonary thromboembolism. He was 30 years old.
Karl lived in Kalgoorlie with his fiancée and their two young daughters. He had significant mental health issues and his diagnoses included drug-induced psychosis and schizoaffective disorder.
In early 2023, Karl’s mental health declined. On 20 February 2023, he did not attend his community mental health service for his four-weekly depot injection of aripiprazole (an anti-psychotic medication). When he attended the next day, his psychiatrist diagnosed an exacerbation of schizoaffective disorder and completed the necessary paperwork for Karl to be psychiatrically assessed at Kalgoorlie Health Campus (KHC).
On 22 February 2023, a consultant psychiatrist at the Mental Health Inpatient Unit (MHIU) at KHC assessed Karl and after diagnosing schizoaffective disorder and polysubstance use disorder, determined that Karl was to be detained as an involuntary patient for mental health treatment under the Mental Health Act 2014 (WA).
Despite various medications to treat Karl, his mental health issues largely remained unresolved during his admission to the MHIU. By 8 March 2023, he had had a full manic relapse.
Karl’s aggressive and threatening behaviour meant the MHIU could no longer safely care for him and the decision was made for him to be urgently transferred by Royal Flying Doctor Service to FSH. Karl was intubated and flown to Perth on 9 March 2023. He was admitted to the ICU at FSH at about 3.30 pm..
Despite a bed being available at the Mental Health Assessment Unit at FSH on 10 and 11 March 2023, Karl could not be extubated on either of those days as no security personnel were available to be present. It had been determined that due to Karl’s previous aggressive behaviour at the MHIU, security were required to be present during the extubation.
Karl was extubated at about 9.30 am on 12 March 2023. Although he initially appeared to be doing well after the extubation, Karl developed a sudden onset of tachycardia (increased heart rate) and lost consciousness before becoming unresponsive. CPR was immediately commenced and Karl was re-intubated, and a prolonged period of resuscitation commenced. Imaging showed a large amount of blood clotting in the right atrium and ventricle, consistent with a massive pulmonary embolus. Despite being given medication to break up this clotting, Karl could not be revived and he died at 12.00 pm.
The coroner was satisfied that given the inadequacies of the MHIU to treat aggressive and acutely unwell patients, the supervision, treatment and care provided to Karl at KHC was adequate. The coroner was also satisfied it was appropriate to intubate Karl for the flight to Perth on 9 March 2023. The coroner identified one missed opportunity by Karl’s treating team at the MHIU to communicate with his family regarding ways to de-escalate his aggressive behaviour.
The coroner was satisfied that the supervision, treatment and care provided to Karl by health service providers in the ICU at FSH was appropriate. The only issue of an otherwise appropriate level of care provided to Karl at FSH was the unavailability of a security officer to be present for an extubation on either 10 or 11 March 2023. However, on the limited information available, the coroner was satisfied there was a reasonable explanation for this not taking place.
No internal investigation (known as a SAC1 investigation) took place regarding the healthcare provided to Karl when he was at FSH. The coroner found that this was a significant oversight.
The coroner made three recommendations regarding the urgent need for a purpose-built mental health facility at KHC and to further enhance the transfer practices of rural and regional mental health patients to metropolitan hospitals.
Catch Words : Mental Health : Involuntary Patient Treatment Order : Security Resources : Referral and Transfer processes in rural and regional areas : Natural Causes
Last updated: 8 January 2026