Inquest into the death of Houston PEEL
Inquest into the Death of Houston PEEL
Delivered on : 30 June 2025
Delivered at : Perth
Finding of : Coroner Jenkin
Recommendations : Yes
Recommendation No. 1
South Metropolitan Health Service (SMHS) should examine ways to improve the treatment and care provided to people presenting at the Fiona Stanley Hospital (FSH) emergency department (ED) with mental health issues by considering measures including, but not limited to:
- providing a therapeutically appropriate waiting area;
- employing mental health clinicians and mental health peer workers to work in the ED waiting room at FSH with the aim of providing support to mental health patients awaiting medical review;
- developing a streamlined process so that once mental health patients have been triaged, they can be reviewed by mental health clinicians, and where appropriate, offered treatment at a much earlier stage; and
- considering whether agencies such as South Australia’s Urgent Mental Health Care Centre provide a model of care which could be offered by SMHS, whether at FSH or elsewhere.
Recommendation No. 2
South Metropolitan Health Service should review the appropriateness of prescribing psychotropic medications to patients presenting to the Fiona Stanley Hospital emergency department with mental health symptoms, without those patients first being reviewed by a doctor.
Recommendation No. 3
South Metropolitan Health Service (SMHS) should consider whether the current system of disseminating Fiona Stanley Hospital (FSH) policies, and SMHS policies to staff at FSH could be improved by filtering or curating the lists of policies being disseminated. The assessment of whether the current system can be improved (and if so how) should include consultation with staff representatives (including junior and senior medical, nursing and allied health staff) with a view to developing a more streamlined system which ensures that staff are made aware of policies applicable to their area (or areas) of clinical responsibility.
Orders/Rules : No
Suppression Order : N/A
Summary : Mr Houston Peel (Houston) died on or about 30 March 2023 at Moitch Park, Murdoch from ligature compression of the neck. He was 29-years of age. Houston was brought to the emergency department (ED) at Fiona Stanley Hospital (FSH) by ambulance on 30 March 2023 at about 4.35 am. Houston’s family had become concerned that he was exhibiting psychotic behaviour, and Houston had agreed to attend FSH to be assessed.
Houston was seen by a triage nurse and assigned a triage score of “3”, meaning he was to be seen within 30 minutes. However, at the relevant time the ED was extremely busy. Although Houston was given some antipsychotic medication and later some paracetamol, he was not seen by a doctor before he left the ED at 8.52 am.
Houston did not answer his name when it was called at about 9.15 am, and at 10.47 am his medical record was marked “did not wait” and he was discharged from FSH. Houston did not contact his family after leaving the emergency department, and that evening his mother reported him to police as a missing person. Houston was discovered by his ex-partner, hanging in bushland opposite FSH on 13 April 2023.
The Coroner concluded that the benefit of hindsight there were missed opportunities where Houston’s care could, and should have been improved and made three recommendations aimed at enhancing the treatment provided to patients with mental health issues who attend the emergency department at FHS.
Catch Words : Mental health presentation : Lengthy wait times : Suicide
Last updated: 14 July 2025