Coroner's Court of Western Australia

Inquest into the Death of James Anthony STANCZYK

Inquest into the Death of James Anthony STANCZYK

Delivered on :16 July 2015

Delivered at : Perth

Finding of : Coroner King

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : Yes

No report of any evidence that could lead to the identification of the deceased’s ex-partner or of the patient in Bay 13 may be published.

Summary : The deceased was 31 years old at the time of his death.  Prior to his death the deceased had presented at the Joondalup Health Campus emergency department following a suicide attempt in which he gassed himself with carbon monoxide in his vehicle and took an overdose of diazepam.

The deceased was treated for carbon monoxide poisoning pending assessment by a psychiatrist in relation to his mental health.  During the evening the deceased became agitated and distressed.  Medical staff were able to calm the deceased and arrangements were made for the security guard who was responsible for another nearby patient to keep an eye on the deceased because of concerns that the deceased had a high risk of suicide and he should not leave the hospital.

On the morning of 23 September 2012 the deceased was assessed by a psychiatric registrar and, because of concerns about his level of risk of self-harm, arrangements were made to place a security guard to watch the deceased on a one-to-one basis.  Before these arrangements were put in place a patient near the deceased became aggressive and violent.  In the commotion that ensued the deceased was able to leave without being immediately noticed.

After leaving the hospital the deceased went to his home in North Perth where he committed suicide by hanging.

The deceased was not an involuntary patient under the Mental Health Act 1996 at the time of his death, however, the Coroner did consider the supervision, treatment and care provided to the deceased while he was a patient at the Joondalup Health Campus.

The issues which were explored at the inquest hearing were whether the deceased could or should have been detained lawfully, whether adequate steps were taken to detain him, if those steps had been taken whether the deceased would have absconded when he did, and what changes have been implemented at the hospital since the deceased’s death.

The Coroner concluded that the evidence before the court established that the professionalism and commitment of the staff at the Joondalup Health Campus emergency department and the Joondalup Heath Campus Mental Health Unit who cared for the deceased was of a uniformly high standard and was characterised by compassion and personal concern.  The Coroner, however, found that, as a result of a number of coincidental factors relating to systemic communication issues, the deceased was allowed to leave the hospital when the deceased was known by all relevant staff to be at high risk of suicide.  The Coroner concluded that the quality of care provided was inadequate.

The Coroner noted that since the deceased’s death, the systemic failures leading to the deceased absconding have been addressed though, in the absence of a place and means of keeping high risk patients in a secure environment before they can be placed in an authorised facility, there remains a concern that mental health patients kept in emergency departments for extended periods are still able to abscond.  The Coroner encouraged those who determine the allocation of resources for mental health services in Western Australia to consider the need for a timely solution.

The Coroner found that the deceased died on 23 September 2012 at Sir Charles Gairdner Hospital from ligature compression of the neck (hanging) and that death arose by way of suicide.

Catch Words : Mental health patient – emergency department : Absconding :  : Security Guards : Suicide


Last updated: 12-Feb-2024

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