Coroner's Court of Western Australia

Inquest into the Death of Quoc Xuan TRAN

Inquest into the Death of Quoc Xuan TRAN

Delivered on : 17 August 2022

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : Yes

The East Metropolitan Health Service should strongly lobby and encourage the Mental Health Commission to use its best endeavours to ensure that the planned Secure Extended Care Units and the Community Care Units are operational as soon as practicable.

Orders/Rules : No

Suppression Order : N/A

Summary : Mr Quoc Xuan Tran (Mr Tran) was born in Vietnam on 23 February 1983, and came to Australia with his family in 1990 on a humanitarian visa.  He initially settled in Victoria, but later moved to Western Australia.  Mr Tran was 36-years of age when he died from immersion (drowning) in the waters of Swan River near Heirisson Island, East Perth.

Mr Tran’s first recorded contact with mental health services was in Victoria in 2002, when he was diagnosed with paranoid schizophrenia.  He was subsequently diagnosed with comorbid anxiety disorder in 2004, and his habitual and impulsive gambling was noted.  At the time of his death, Mr Tran’s diagnoses were schizoaffective disorder and autism spectrum disorder.  He regularly reported auditory hallucinations and at times, he exhibited aggressive and/or agitated behaviour.

Mr Tran’s chronic mental illnesses and complex behavioural needs were largely managed in the community on a succession of Community Treatment Orders (CTO).  On several occasions when his mental health deteriorated, he was admitted to psychiatric facilities.  Mr Tran was under the care of a community psychiatric service and his complex needs were managed by means of a monthly depot injection of antipsychotic medication.

A CTO was required in Mr Tran’s case because lacked insight into his mental health conditions and was unable to make treatment decisions about his mental health.  There was also a concern that he may be non-compliant with his medication.

The coroner was satisfied that the decision to place Mr Tran on successive CTOs was justified on the basis that this was the least restrictive way to ensure that Mr Tran was provided with appropriate treatment for his mental health conditions.  The coroner was also satisfied that the supervision, treatment and care that Mr Tran received whilst he was an involuntary patient in hospital and whilst he was the subject of a succession of CTOs, was appropriate and of a good standard.

In the last 30-months of his life, Mr Tran was evicted from his accommodation on five occasions and his mental state deteriorated each time this occurred.  The coroner observed that the management of Mr Tran’s mental illnesses was hampered by the lack of appropriate accommodation options.  The coroner noted that the Mental Health Commission (Commission) is planning to open facilities to cater for people like Mr Tran with complex needs and a history of chronic mental illness, and recommended that the East Metropolitan Health Service strongly lobby and encourage the Commission to open the planned secure extended care units and community care units as quickly as possible.

Catch Words : Death in care : Community Treatment Order : Accommodation options for mental health patients with complex needs : Open finding


Last updated: 26-Aug-2022

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