Coroner's Court of Western Australia

Inquest into the Death of Jordan James WILLIAMS

Inquest into the Death of Jordan James WILLIAMS

Delivered on : 25 February 2022

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : Yes

Recommendation No. 1

The Western Australian Country health Service (WACHS) should take immediate steps to ensure that the remediation works needed to raise the height of the boundary fencing of the courtyard attached to mental health unit at the Kalgoorlie Health Campus are urgently completed.  This remediation work should be made an absolute priority by WACHS.

Recommendation No. 2

The Western Australian Country Health Service should approach the lessee of the railway line at the rear of the Kalgoorlie Health campus (KHC) and advise that the chain link fence running along that railway line needs urgent inspection with a view to upgrading the fence (as soon as reasonably practicable) so that it properly restricts access to the railway tracks in the vicinity of KHC.

Recommendation No. 3

The Western Australian Country Health Service (WACHS0 should urge the Department of Finance to fast-track the WACHS proposal to construct a purpose-built mental health facility at the Kalgoorlie Health Campus so that construction of the facility can start as soon as possible. WACHS should also undertake detailed planning to ensure that when opened, the new facility is appropriately staffed by mental health and allied health professionals.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Williams died on 24 August 2018, after being struck by a train on railway tracks at the rear of the Kalgoorlie Health Campus (KHC) near the Maritana Bridge in Kalgoorlie.  At the time of his death Mr Williams was 20-years of age and was an involuntary patient under the Mental Health Act 2014 (WA) (MHA).  The inquest focused on the circumstances of Mr Williams’ death and the supervision, treatment, and care he received while he was an inpatient at the KHC.

Following the death of his mother in 2016 and his father in February 2018, Mr Williams’ mental health declined and he began using illicit drugs.  In about July 2018, Mr Williams recommenced his apprenticeship but his employment was terminated on 17 August 2018, due to his erratic behaviour at work.  The same day, his former employer became concerned for Mr William’s mental state, and contacted Police.  However, when police spoke to Mr Williams at his home, he showed no signs of distress and his housemates raised no concerns for his welfare.

On 20 August 2018, Mr Williams’ housemate contacted police because she was concerned about his behaviour.  Police attended and Mr Williams said he was struggling and had been hearing voices who were telling him to hurt himself.  He agreed to be taken to KHC for assessment, where he was diagnosed with psychosis and admitted to a surgical ward because the mental health unit at KHC (the MHU) was already at capacity.

At about 12.45 pm on 22 August 2018, Mr Williams returned to the ward after escorted leave following a visit from family members.  He was crying inconsolably and saying he wanted to die and that his relatives were trying to kill him.  Mr Williams was reviewed by his treating psychiatrist and later by the psychiatric registrar.  Mr Williams’ antipsychotic medications were increased, his escorted leave was cancelled.

On 23 August 2018, Mr Williams was transferred to the MHU when a bed became available.  After he attempted to harm himself with hot water and to abscond from the MHU, he was made an involuntary patient at 3.15 pm when he was placed on Inpatient Treatment Order under the MHA.

At about 6.00 pm on 24 August 2018, Mr Williams absconded from the MHU by scaling the rear fence of the attached courtyard.  He was apprehended by security guards in the vicinity of the railway tracks at the rear of KHC and returned to the MHU.

At about 7.30 pm, Mr Williams was given permission to go into the courtyard to recover cigarettes he had previously given to other patients.  He was accompanied by a nurse and a security guard.  Whilst he was in the courtyard, some of the patients were kicking a football and Mr Williams and the security guard joined in,  Suddenly, Mr Williams ran to the rear fence of the courtyard which he again scaled.  The security guard chased after Mr Williams but was unable to stop him from running onto railway tracks at the rear of KHC.  Mr Williams was struck by a train as he lay on the tracks and died from the catastrophic injuries he sustained.

The Coroner made three recommendations aimed at improving the MHU and suggested that the WA Country Health Service make urgent approaches to the lease of the land on which the railway tracks are situated with a view to upgrading the section of the perimeter fence at the rear of KHC..

Although the Coroner was satisfied that the standard of treatment and care provided to Mr Williams during his admission was appropriate, the Coroner found that the standard of supervision Mr Williams received was demonstrably sub-optimal.  The Coroner expressed the view that Mr Williams should have been allocated a 1:1 special by a nurse at the time he was made an involuntary patient.

Catch Words : Involuntary Patient : Death in Care : Supervision, Treatment and Care : Use of Security Guards in a Mental Health Facility : Recruiting Mental Health Staff : Purpose Built Facility for Mental Health Patients : Suicide


Last updated: 6-Oct-2023

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