Coroner's Court of Western Australia

Inquest into the Death of James Ronald CHI

Inquest into the Death of James Ronald CHI

Delivered on :30 August 2019

Delivered at : Perth

Finding of : Deputy State Coroner King

Recommendations :Yes


That relevant government agencies consider the desirability and feasibility of establishing a facility providing long-term supported accommodation for mental health patents in the Kimberley region.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was an involuntary patient under the Mental Health Act 2014. On 26 June 2017 the deceased died in the emergency department at Broome Hospital from chronic obstructive pulmonary disease and coronary artery atherosclerosis. He was 69 years old.

The deceased was one of Australia’s most celebrated playwrights and musicians.

The deceased’s medical history included treatment resistant bipolar affective disorder, heavy cigarette smoking and chronic obstructive pulmonary disease with emphysema, but despite receiving repeated advice to quit was still unwilling to stop smoking. He also had coronary artery disease, type 2 diabetes, renal dysfunction, malnutrition, gastroesophageal reflux disease and pseudo bowel obstruction from chronic constipation. All these conditions were treated with medications and diet modification. From about 2013 he developed significantly disabling Parkinsonism, with tremor, bradykinesia and postural instability, from long exposure to first generation antipsychotic depot medications.

In the 1970’s the deceased was diagnosed with bipolar affective disorder. His mental illness became increasingly difficult to manage with the bipolar cycles became more frequent and extreme. In late 2014 the deceased was admitted as an involuntary patient to Mabu Liyan, the mental health unit at Broome Hospital, where he effectively remained until his death. The last order for continuation of the deceased’s status as an involuntary patient under an inpatient treatment order was made on 19 June 2017.

In the week or so before his death the deceased appeared to be in high spirits. He was feeling physically stronger with an improved mood, and he was compliant with his medication. On the morning of 26 June 2017 he was reactive and elevated but was still pleasant and polite. Later in the afternoon he became breathless after an outburst in which he was yelling. He was administered salbutamol, and the medical emergency team was called.

The medical emergency team transferred the deceased to the emergency department. He was displaying agonal breathing and worsening bradycardia, but due to a ‘not for resuscitation’ order the emergency medical team took no further steps to revive him. He died shortly thereafter.

The Coroner made a recommendation relating to improving long term supported accommodation for mental health patients in the Kimberley.

Catch Words : Mental Health Act 2014 : Involuntary Patient : Mabu Liyan : Bipolar Affective Disorder : Clozapine Long Term Accommodation in Kimberley Region : Natural Causes

Last updated: 14-Nov-2019

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