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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 2014→Church, Lynn Desmond Ernest

Inquest into the Death of Lynn Desmond Ernest CHURCH

Delivered on:  11 June 2014

Delivered at: Perth

Finding of: Coroner King

Orders/Rules:  N/A

Suppression Order:  N/A

Summary:    The deceased was a 64 year old man who at the time of his death was a patient at the Joondalup Health Campus Mental Health Unit and who was an involuntary patient under the Mental Health Act 1996.

The inquest focused on the circumstances surrounding the deceased’s quality of supervision, treatment and care provided while the deceased was in care. The inquest also examined –

  • management of communication between the Joondalup Health Campus Mental Health Unit and the families of patients;
  • the transfer of the deceased to an open ward despite warnings;
  • the use of 15 minute monitoring of the deceased;
  • the quality of the monitoring by nurses;
  • the availability of plastic bags on the open ward.

The Coroner found the deceased died between 6 July 2010 from plastic bag asphyxia. With respect to the manner of death the Coroner found that the deceased suicided.

Catch Words:  Mental Health – communication – open wards – monitoring – plastic bags - suicide


Last updated: 1-Feb-2024

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