Coroner's Court of Western Australia

Inquest into the Death of Mary Josephine Van der WALT

Inquest into the Death of Mary Josephine Van Der WALT

Delivered on :15 September 2017

Delivered at : Perth

Finding of : Coroner King

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased lived with a flat-mate in a unit in Maylands. She had depression and anxiety and had been diagnosed with borderline personality disorder.  She was 28 years old at the time of her death.

On 21 April 2014 called ‘000’ to say that she had found a body at her home. Police attended the deceased’s unit and found her hanging from the beams on a pergola.  They checked her wrist for pulse and noticed that she was warm to touch, but could not detect a pulse.  They called for an ambulance and cut the ligature to lower her to the ground.  A police officer checked for a carotid pulse and found none.  The deceased’s pupils did not react to light.  The police officers decided not to administer CPR as it was their understanding at the time that they were to determine whether the deceased was still alive before commencing CPR.

When St John Ambulance paramedics arrived at the deceased’s unit minutes later, they confirmed that the deceased was pulseless and that her heart rhythm was asystole. They commenced CPR with adrenaline therapy and were able to return the deceased’s spontaneous circulation.  They took her to RPH emergency department, but it was clear that she had hypoxic brain injury.  Her condition deteriorated and, on 23 April 2014, test results indicated brainstem death.

The focus of the inquest was on the police officers’ decision not to administer CPR and on the training provided to police officers to deal with similar circumstances. The evidence established that, at the time of the deceased’s death, police officers were trained to determine whether a non-responsive person was alive before administering CPR.  Since then, the training has changed to require CPR to be administered to persons who were unresponsive and not breathing, without considering if the person is still alive.

The coroner was satisfied that the police officers’ actions accorded with their training, and that it was not possible to determine whether the deceased would have survived if they had administered CPR.

The coroner found that the cause of death was complications of ligature compression of the neck and that death occurred by way of suicided. The coroner encouraged Western Australia Police to equip police vehicles with automated external defibrillators (AEDs).

Catch Words: Police Administering CPR : AEDS in Police Vehicles : Suicide : Hanging

Last updated: 2-Oct-2017

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