Coroner's Court of Western Australia

Inquest into the Death of Nualla Christine REILLY

Inquest into the Death of Nualla Christine REILLY

Delivered on :26 May 2020

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Ms Reilly was a 74 year old woman who had a long history of mental health issues, including a longstanding personality disorder. Ms Reilly’s psychiatric conditions became increasingly difficult to manage and she had a number of hospital admissions in late 2016 and early 2017 related to her deteriorating mental state, which included suicidal thoughts and attempts.

In early 2017 Ms Reilly experienced a significant relapse of her mental health conditions that led to a prolonged stay at the Bentley Hospital. It was decided by medical staff and her family during that admission that she was no longer safe to live at home on her own. It was intended that she would move from hospital to a nursing home facility near her family. Ms Reilly was consulted and was willing to move to an aged care facility. Ms Reilly was transferred to a transitional care facility while a suitable placement was found at a nursing home. However, Ms Reilly was unhappy at the transitional care facility and on 9 June 2017 she attempted suicide. She was taken to Fiona Stanley Hospital for medical review and while there she indicated to hospital staff that she had attempted suicide as she felt it was the only way to resolve her current crisis. Ms Reilly was assessed as still being actively suicidal. She indicated she did not want to return to the transitional care facility nor Bentley Hospital.

Ms Reilly was reviewed by a psychologist and a decision was made that she would be referred to Bentley Hospital on forms for psychiatric review. Ms Reilly was informed of this decision. While psychiatric staff completed the relevant paperwork, there was some confusion amongst Emergency Department nursing staff as to what was happening with Ms Reilly. In the confusion, Ms Reilly was mistakenly permitted to leave the hospital unaccompanied. She travelled by taxi to Victoria Park Train Station, where she caught a train to Carlisle Train Station. After arriving at Carlisle Train Station, Ms Reilly left the platform and deliberately walked on to the train tracks, where she was hit by an oncoming train. Ms Reilly suffered fatal injuries and died at the scene.

The Coroner was satisfied Ms Reilly’s death was an intentional act of suicide.

Catch Words : Managing Mental Health Patients : Suicide

Last updated: 16-Jul-2020

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