Inquest into the Death of Karl Jonathan TURNER
Inquest into the Death of Karl Johnathan TURNER
Delivered on : 20 September 2024
Delivered at : Perth
Finding of : Coroner Jenkin
Recommendations : No
Orders/Rules : No
Suppression Order : N/A
Summary : Karl Johnathan Turner (Karl) died on 6 December 2022 at his home in Tuart Hill, from combined drug toxicity. He was 49-years of age. At the request of his family, Mr Turner was referred to at the inquest, and the coroner’s finding as “Karl”.
Karl’s medical history included schizoaffective disorder, depression, cellulitis, drug-induced psychosis, chronic lower back pain, and Attention Deficit Hyperactivity Disorder. On 9 May 2017, Karl was admitted to Graylands Hospital for two weeks, and diagnosed with schizophreniform psychosis. He was treated with olanzapine and sodium valproate, and after his symptoms had settled he was discharged home
In early April 2018, Karl experienced an apparent psychotic episode whilst working as a seaman on a vessel in Darwin. He was admitted to Darwin Hospital on an involuntary basis, and diagnosed with a psychotic episode with manic features. He was discharged home on 24 April 2018.
The management of Karl’s mental health was exacerbated by his persistent polysubstance use, and when his mental health deteriorated, he was admitted to psychiatric hospitals. In addition to his admissions to Graylands Hospital in 2017, and Darwin Hospital in 2018, Karl was also admitted to Graylands on several occasions between 2019 and 2022 as an involuntary patient, and to Bentley Hospital as an involuntary patient in 2021.
Karl was also managed in the community on a series of community treatment orders (CTO). A CTO was required in Karl’s case because he was non-compliant with his medication regime, and lacked insight into his mental illness. In addition to disputing his diagnosis and his need for treatment, Karl also expressed a mistrust of mental health services, and he regularly failed to attend scheduled appointments.
On 14 September 2022, Karl’s care was transferred to the Intensive Clinical Outreach Team at Osborne Clinic (ICOT), a service which works with people with persistent and enduring mental illness and comorbidity who have often been excluded from mainstream mental health services because of aggression or antisocial behaviours.
Karl was last seen by his caseworker on 29 November 2022. No signs of acute risk to self or others were noted, and a further visit was planned the following week.
At about 6.40 pm, detectives from the Regional Investigations Unit arrived at Karl’s home to investigate “a high-risk electronic monitoring breach” relating to someone who was thought to be at Karl’s home. During their search of the property, the detectives found Karl lying, unresponsive, on his garage floor. The officers requested an ambulance before starting CPR. Ambulance officers arrived a short time later and took over resuscitation efforts, but Karl could not be revived. He was declared deceased at 6.57 pm on 6 December 2022.
The coroner found that Karl’s physical health (including his heart health) should have been regularly monitored because of the potential side effects of the medications he was taking. Nevertheless, the coroner found there was no evidence that the failure to conduct these regular reviews was in any way connected to the cause of Karl’s death.
The coroner was satisfied that it was appropriate for Karl to be placed on a CTO given his lack of insight into his mental illness and his need for treatment. The coroner also found that the standard of supervision, treatment and care Karl received whilst he was the subject of a CTO was reasonable, particularly when considered in the context of the resources available to his treating clinicians at the relevant time.
Catch Words : Community treatment order : Substance misuse : Accident
Last updated: 12-Oct-2024
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