Coroner's Court of Western Australia

Inquest into the Death of Carly Jean ELLIOTT

Inquest into the Deaths of Ruby Natasha NICHOLLS-DIVER and Carly Jean ELLIOTT and Michael Ronald THOMAS and Anthony Ian EDWARDS and Stephen Colin ROBSON (known as Alma Street Centre)

Delivered on :31 December 2015

Delivered at : Perth

Finding of : State Coroner Fogliani

Recommendations :Yes

In connection with the information to be provided to family members/carers (“carers”) into whose care a mental health patient is discharged, the State Coroner made the following recommendation:

I recommend that the Western Australian Department of Health develop policies and procedures for the implementation of Carer’s Plans, and that such policies and procedures address matters of patient consent and risk issues, and that the following matters be explored for inclusion in Carer’s Plans –

  • information concerning the diagnosed condition and medication regime;
  • information relevant to a relapse prevention plan;
  • information relevant to guidance as to when to proactively re-engage with the mental health services;
  • information relevant to the individual needs and concerns of the carers; and

information relevant to support services available to carers.

In connection with the continued funding and resourcing of mental health services, the State Coroner made the following recommendation:

I recommend that for the purposes of implementing improvements in the delivery of mental health services, the Western Australian government continues its efforts to provide the funding and resources required to progress the Stokes Review recommendations and the Chief Psychiatrist’s standards from the planning stage to the implementation stage

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deaths of five former patients of the psychiatric unit known as Alma Street Centre, which comprised a part of the mental health services of Fremantle Hospital, were investigated at one inquest.  The patients died within a twelve month period, between March 2011 and March 2012.  Two of the former patients died within 24 hours of being discharged.  One was an involuntary patient who absconded and died that same day.  One former patient disappeared within 24 hours of being discharged and was subsequently located, deceased.  One former patient died one month after her last contact with Alma Street Centre.

The focus of the inquest was upon the actions taken by the mental health clinicians during the period leading to the deaths of the five former patients.  This included a review of their clinical judgements, and a review of their communications with the deceased’s family members/carers, particularly where the deceased were being discharged from the mental health facility..

The State Coroner found that all of the deceased died by suicide.   The causes of death in respect of each deceased are addressed in the finding.

Catch Words : Alma Street : Mental Health: Suicide : Absconding : Communication :Carers : : Carer’s Plans : Resourcing :

Last updated: 5-Jul-2024

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