Coroner's Court of Western Australia

Inquest into the Death of Vincent Tavita Tolai SCHWENKE

Inquest into the Death of Vincent Tavita Tolai SCHWENKE

Delivered on : 15 January 2018

Delivered at : Perth

Finding of : Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased at the time of his death was an involuntary patient receiving care for a mental health condition at St John of God Public Hospital in Midland.

The focus of the inquest was primarily on the medical care and supervision provided to the deceased while a patient at Royal Perth Hospital and St John of God Public Hospital in Midland, and events leading up to the incident where he was found hanging.

The deceased was a 24 year old man who developed sudden onset symptoms of psychosis and mood disorder with suicidal thoughts. With support from his family the deceased took appropriate steps to obtain medical treatment from his general practitioner and later presenting at a hospital Emergency Department as his symptoms escalated.  He was admitted to St John of God Public Hospital Midland on 8 December 2015 as an involuntary patient.  Before a clear diagnosis was made for his psychotic symptoms, and while an involuntary patient at St John of God Public Hospital, the deceased sustained irreversible brain damage after attempting to hang himself in his room.

The Coroner noted the difficulty for medical staff as the deceased’s suicidal ideation appeared to be fluctuating, which made it very difficult to pick when he might be suicidal. The evidence suggested the deceased’s mental state had undergone a change on the morning that he hanged himself and he had woken up actively suicidal.  The Coroner noted that it was difficult to conclude the deceased’s full capacity to understand that he might die from his actions.  The Coroner noted the deceased’s actions may have been affected by his psychosis, given there was an element of lack of rationality in his behaviour overnight.  The Coroner concluded there was not enough evidence that the deceased was in a position to know and understand the nature and consequences of his actions and accordingly, made an Open Finding as to the manner of death.

The Coroner concluded the deceased received a reasonable standard of medical care and the evidence suggested his death was unpredictable and unexpected.

Catch Words : Involuntary Patient : Hospital Procedures : Ligature Risk Minimisation : Open Finding

Last updated: 30-Apr-2019

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