Coroner's Court of Western Australia

Inquest into the Death of Jacob George Isaac TAULELEI

Inquest into the Death of Jacob George Isaac TAULELEI

Delivered on: 26 May 2023

Delivered at: Perth

Finding of: Coroner Jenkin

Recommendations: N/A

Orders/Rules: N/A

Suppression Order: N/A


Jacob George Isaac Taulelei (Mr Taulelei) died at 12.30 am on 8 February 2020, after he was struck by a train on tracks adjacent to Railway Parade in Midland.  He was 28-years of age. Mr Taulelei had a long-standing history of mental health issues, and he and his mother presented to St John of God Midland Public Hospital (SJOG) on 5 February 2020. Although Mr Taulelei told clinical staff he wanted to jump in front of a train or bus, he was discharged into his mother’s care, and referred to a community mental health service, and his GP.

On 7 February 2020, Mr Taulelei sent a Facebook message to his mother containing a link to a song he said he wanted played at his funeral. She took him back to SJOG, where Mr Taulelei again told staff he planned to jump in front of a bus or train. Before she left SJOG to go home, a doctor told Ms James that Mr Taulelei would be admitted to the hospital’s mental health unit. In fact, after Mr Taulelei was assessed by a psychiatric registrar, he discharged home shortly before midnight. Further, although his mother had specifically asked to be told if Mr Taulelei left SJOG, this did not occur.

The coroner was satisfied that that the risk assessment conducted by the psychiatric registrar was unsatisfactory and that Mr Taulelei should have been admitted to SJOG when he presented there on 7 February 2020. Further, the coroner said it was clear that because of the close (and obvious) involvement she had in his care, Mr Taulelei’s mother ought to have been contacted before Mr Taulelei was discharged from SJOG just before midnight on 7 February 2020. For these reasons, the coroner found that Mr Taulelei’s care at SJOG was demonstrably substandard.

Catch Words: Discretionary Inquest: Mental Health: Risk assessment : Suicide: Hospital Discharge

Last updated: 30-Jun-2023

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