Coroner's Court of Western Australia

Inquest into the Death of Brook Damian CAIN

Inquest into the Death of Brook Damian CAIN

Delivered on :27 June 2018

Delivered at : Perth

Finding of : Coroner King

Recommendations :Yes

The Commissioner of Police consider and, if appropriate, implement regular in-service training of operational police officers in relation to mental health related issues.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was subject to a community treatment order (CTO) under the Mental Health Act 1996 at the time of his death.  He was 39 years of age.

At an early age the deceased began to abuse cannabis and alcohol and tried other drugs. He became addicted to amphetamine and at about 23 years of age he began to experience severe mental health problems.  In 2006 he was diagnosed with drug-induced psychosis.  That diagnosis was later revised to schizophrenia and then schizoaffective disorder with anti-social personality traits.  He had a history of self-harm and suicide attempts when he was acutely unwell.  He was involved with mental health facilities as a voluntary patient, an involuntary in-patient and as an out-patient on a CTO.  Difficulties in treating him were compounded by his lack of insight, non-compliance with oral medication and on-going drug abuse, which exacerbated his symptoms.

On 12 November 2014 the deceased had an altercation with an acquaintance, leading to the deceased throwing a vase through the acquaintance’s window and threatening him with a knife. Police arrested the deceased and took him to the police station to charge him.  The deceased’s mother contacted the police station to ask that police take the deceased to Bunbury Hospital for mental assessment.  The deceased showed no indication that he was in danger of self-harm or that he required assessment, so police officers took him home after charging him.  

The next morning, the deceased’s mother was unable to contact the deceased, so she rang the deceased’s case manager, who conducted a welfare check and found the deceased hanging by the neck with washing line tied to a be pergola in the rear yard of his unit.

The Coroner found that the deceased died on or about 13 November 2014 from ligature compression of the neck (hanging) and that death occurred by way of suicide. The Coroner made a recommendation aimed at improving the training of police officers when dealing with persons with mental health issues.

Catch Words: Community Treatment Order : Mental Health Act 1996 : Police training :  Drug-induced psychosis : Amphetamine : Schizoaffective disorder : Suicide : Hanging

Last updated: 30-Apr-2019

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