Coroner's Court of Western Australia

Inquest into the Death of John Vincent KEARNEY

Inquest into the Death of John Vincent KEARNEY

Delivered on : 26 February 2015

Delivered at : Perth

Finding of : State Coroner Fogliani

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary :  The deceased was a 49yo married man with children, who had experienced mental health problems to varying degrees over a number of years. He had not had ongoing treatment. Shortly before his death the deceased was referred by his GP to the Emergency Department (ED) of Sir Charles Gairdner Hospital (SCGH) following a mental health assessment.

The deceased was immediately taken by his wife to the ED of SCGH and after triage and assessment by a mental health nurse, that night he received a comprehensive psychiatric assessment. The psychiatry registrar formed the view that the deceased had an acute stress reaction and no formal thought disorder or psychosis. The psychiatry registrar decided to admit the deceased to the ED for overnight observation with the intention of considering alternatives for voluntary admission and/or discharge with community support the next day.

The next morning the deceased’s care and treatment was handed over to the psychiatry registrar on the day shift, the deceased was assessed by the mental health team and a discharge plan was made in consultation with the deceased and his brother. It included follow up care for the deceased in the community, through the Transition Program. The deceased’s mental state continued to apparently improve. The deceased was assessed by another psychiatry registrar and social worker in the community, as being at low risk of suicide.

Shortly after that assessment, the deceased died from carbon monoxide toxicity. The State Coroner found the manner of death was suicide.

Catch Words :. Psychiatric assessment – Sir Charles Gairdner Hospital – handover - discharge planning – Transitions Program – Hospital in the Home – carbon monoxide toxicity - suicide


Last updated: 11-Mar-2024

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