Coroner's Court of Western Australia

Inquest into the Death of Justine PAINTER

Inquest into the Death of Justine PAINTER

Delivered on :7 October 2022

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Justine Painter (Ms Painter) was 51 years old when she died on 15 March 2020.  Ms Painter had developed very serious physical and mental health issues after many years of drug and alcohol abuse and was in poor general health for her age.  Ms Painted lived in a secure care facility at the Mosman Park Aged Care and Home.  Some aspects of Ms Painter’s life was managed by a public guardian, including where she lived and health care decisions.

Due to Ms Painters significant health issues, she was sometimes required to attend hospital for treatment.  Most of her care in her final years was coordinated at Royal Perth Hospital.  On 28 May 2020, she attended at RPH for a pre-planned admission to the gastroenterology department for a blood transfusion.  Originally her admission was for her to stay overnight, but the admission was extended over a weekend.  While in the hospital, Ms Painter was no longer in a secure environment and staff at the hospital were not aware of her potential to abscond and potentially to self-harm, although that information was available.  After a short period of time, Ms Painter was allowed to regularly leave the hospital unsupervised.

On 4 June 2020, Ms Painter walked out of the hospital in her hospital gown.  She walked approximately 500 metres from the hospital to a multi-storey public carpark.  After making her way upstairs to the top of the multi-storey carpark, she sat on the retaining wall edge and pushed herself off the edge and fell to the footpath below.  Ms Painter died as a result of multiple injuries sustained in the fall.

The Deputy State Coroner noted that it was apparent that there were communication issues between RPH staff and the Mosman Park Home staff, and internally between the RPH staff, which led the RPH nursing staff to underestimate Ms Painter’s risk of absconding and self-harm.  The Mosman Park Home staff had tried to communicate this information, but it was not received by the relevant people.

The Court was advised that the East Metropolitan Health Services have, since Ms Painter’s tragic death, taken proactive steps to change policy to ensure that relevant information is obtained from external facilities when a patient such as Ms Painter is admitted, and that information is then shared with all of the health staff who are responsible.

Catch Words : Vulnerable Patients : Communication of relevant information from external facilities : Admission process : Risk Flags : Open Finding

Last updated: 13-Dec-2022

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