Coroner's Court of Western Australia

Inquest into the Death of Paul McLOUGHLIN

Inquest into the Death of Paul McLOUGHLIN

Delivered on : 8 April 2024

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : No

Orders/Rules : No

Suppression Order : N/A

Summary : Paul McLoughlin (Paul) died on 21 January 2022 at his family home, from incised injuries to the neck.  He was 59-years of age.  At the request of his family, the deceased was referred to at the inquest and the coroner’s finding as “Paul”.

Paul had a long-standing history of mental illness and had been a patient of a community mental health service since 1998.  He had a long-standing history of heavy, daily cannabis use and had been variously diagnosed with bipolar affective disorder, schizoaffective disorder, drug-induced psychosis, cannabis amotivational syndrome, generalised anxiety disorder with depressive features, dysthymia (milder, but long lasting form of depression), and dependent personality disorder.

Paul had been admitted to Sir Charles Gairdner Hospital (SCGH) a number of times and had received electro-convulsive therapy on eight occasions.  He had also been admitted to Graylands Hospital (Graylands) on five occasions since 2018, and he had attempted to take his life in 2003, 2008, 2018, and 2020 by medication overdoses of “high lethality”.

On 4 January 2022, Paul presented to SCGH in the company of his family.  He had expressed suicidal ideation, and he was made an involuntary patient and transferred to Graylands for assessment.  Paul was diagnosed with generalised anxiety disorder with depressive symptoms/dysthymia, and he was also considered to have cluster C personality disorder with dependent and anxious avoidant features.  He was placed on an inpatient treatment order made under the Mental Health Act 2014 (WA), and a two to three week admission was planned to allow detoxification from cannabis, monitoring of Paul’s mental state, and respite for his wife.

Paul’s mental state improved during his admission and he was permitted to leave Graylands on “day leave” with his family.  Paul successfully completed several periods of day leave without incident, and at about 3.00 pm on 21 January 2022, Paul’s wife collected him from Graylands for a further period of leave.

Paul and his wife did some shopping and arrived at the family home at about 5.15 pm and sat in the backyard chatting until about 6.00 pm, when Paul’s wife went inside to prepare dinner.  Although Paul seemed somewhat anxious this was not unusual, and nothing about their conversation, or his presentation gave Paul’s wife any cause for concern.  Dinner was ready at about 6.40 pm, and Paul’s wife went into the backyard to let Paul know, but he was nowhere to be seen.  When she looked through the window of the back shed, she saw Paul lying face down next to a pool of blood.  Paul had cut his throat and emergency services were called.

Police and ambulance officers arrived a short time later and started CPR, but Paul could not be revived.  He was declared deceased at 7.05 pm on 21 January 2022.  A forensic pathologist conducted a post mortem examination and expressed the opinion that the cause of Paul’s death was incised injuries to the neck.

The coroner was satisfied that it was appropriate for Paul to be placed on an inpatient treatment order and managed as an involuntary patient, given Paul’s initial suicidal ideation, and his inability to guarantee his safety.  The coroner was also satisfied that Paul’s actions in taking his life could not have been anticipated, and that it was appropriate for him to have been granted day leave with his family on 21 January 2022.

After carefully considering the available evidence, the coroner concluded that the supervision, treatment and care that Paul received while he was an inpatient at Graylands was of a good standard.

Catch Words : Inpatient treatment order : Chronic self-harm risk : Suicide

Last updated: 19-Apr-2024

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