Inquest into the Death of Martin Carl QUITERIO
Delivered on: 27 May 2026
Delivered at: Perth
Finding of: Brendyn Dean Nelson
Recommendations: Yes
Orders/Rules: No
Suppression Order: N/A
Summary:
Martin Carl Quiterio died on 3 January 2024 in West Perth after jumping from a multi-storey car park. He died from multiple traumatic injuries, and the Coroner found his death occurred by way of suicide.
Martin had been discharged from Sir Charles Gairdner Hospital on 28 December 2023 under a community treatment order. The Coroner found his treatment, supervision and care were appropriate and of an acceptable standard. The Coroner found appropriate risk assessments were undertaken on the morning of 3 January 2024 by those interacting with Martin, and no further escalation was reasonably required.
The Coroner examined issues including the absence of a formal assessment for suspected Autism Spectrum Disorder (ASD), continuity of care and discharge planning. Although ASD was repeatedly raised and considered, no formal diagnosis was obtained, reflecting broader gaps in access to public services.
Recommendation 1:
The Department of Health take all reasonable steps to expedite the feasibility study for, and (if considered feasible) the introduction of, a State-wide Neuropsychiatric Consultation Liaison Service, to provide consultation and support to clinicians concerning conditions including autism spectrum disorder, as well as training and resources in relation to the same (including by obtaining additional funding to the extent it is required).
Recommendation 2:
The Department of Health engage with all Health Service Providers (HSPs) with in-patient mental health units, regarding those HSPs employing carer support workers within those units, with the role of providing support to families and carers of patients.
Catch Words: Community Treatment Order : Suicide
Last updated: 3 June 2026