Coroner's Court of Western Australia

Inquest into the Death of Annette SILVER

Inquest into the Death of Annette SILVER

Delivered on :22 June 20175

Delivered at : Perth

Finding of : Coroner King

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was an involuntary patient under the Mental Health Act 1996 at the time of her death.  She had a history of depression and suicide attempts.

On 30 November 2014 the deceased was admitted into an open ward at Bentley Hospital with possible adjustment depression with anxiety/depression. She was re-started on a new antidepressant and referred to a psychologist for psychotherapy.

On 2 December 2014 the deceased’s psychiatrist formed the impression that she had experienced a major depressive episode with cluster C personality traits and planned to discharge her to stay with a sister with follow up by a private psychiatrist. Over the next three days the deceased’s condition appeared to improve.

On 5 December 2014 the deceased was discharged. Her sister attended the hospital and expressed concerns about the deceased’s high level of anxiety.  The deceased was then given weekend leave with her family, with the option to return early if she was not feeling comfortable.

On 8 December 2014 the deceased returned to Bentley Hospital after having expressed suicidal intentions over the weekend. She was made an involuntary patient until 7 January 2015 and was placed in an open ward.

On 12 December 2014 the deceased appeared pleasant and compliant but then left the hospital and did not return that day. Hospital staff searched for her without success and notified police that she was missing.  On 13 December 2014 the deceased returned to Bentley Hospital unassisted.  She advised that she had left the hospital to end her life, but realised that she could not do so.  She was transferred to the secure ward and placed on 15 minute observations.

The deceased appeared to improve over the next two weeks. On 26 December 2015 she was moved into an open ward.  On the evening of 2 January 2015 she left the hospital and went to the nearby train line where she stood in the path of an on-coming railcar, which struck her and caused her multiple injuries which caused her death.

The Coroner found that death occurred by way of suicide.

The Coroner found that the supervision, treatment and care of the deceased was reasonable and generally appropriate in the circumstances.

Catch Words : Mental Health : Depression : Suicide : Involuntary Patient.

Last updated: 30-Apr-2019

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