Inquest into the Death of Samaan Salah Tilmiz ELSAMIN
Inquest into the Death of Samaan Salah Tilmiz ELSAMIN
Delivered on : 22 July 2025
Delivered at : Perth
Finding of : Coroner Jenkin
Recommendations : No
Orders/Rules : No
Suppression Order : N/A
Summary : Samaan Salah Tilmiz Elsamin (Mr Elsamin) was 21-years of age when he died at Joondalup Health Campus (JHC) on 9 November October 2022. Despite a thorough post mortem examination, the cause of Mr Elsamin’s death could not be ascertained, and the coroner made an open finding as to the manner of Mr Elsamin’s death.
Mr Elsamin was diagnosed with severe, treatment resistant schizophrenia, and a moderate to severe intellectual impairment. He had a history of polysubstance use including alcohol and cannabis (and possible solvent use), as well as frontal lobe dysfunction with sexual disinhibition. Mr Elsamin also presented with extremely challenging behaviours including aggression, and a proclivity to unpredictable, violent assaults against those around him including family members, carers, clinical staff and hospital security officers. Mr Elsamin’s treatment and care was further complicated by his limited verbal skills
At the time of his death, Mr Elsamin was the subject of an involuntary treatment order (ITO) made under the Mental Health Act 2014. An ITO was required in Mr Elsamin’s case because his serious mental illness and his intellectual disability meant he was a risk to himself and others. Mr Elsamin also lacked insight and did not have the capacity to make treatment decisions about his mental health
Mr Elsamin was managed in the Psychiatric Intensive Care Unit (PICU) at JHC and clinical staff managed his complex needs by a combination of proactive management strategies, de-escalation attempts, sedatives, physical restraint and seclusion. The PICU was not an appropriate place for Mr Elsamin to receive long-term care, but there were no appropriate facilities to which Mr Elsamin could be transferred for long-term care.
During the day on 9 November 2022, Mr Elsamin’s behaviour escalated, and just before 7.00 pm on 9 November 2022, Mr Elsamin was placed in a seclusion room at the PICU, and restrained for about 25 minutes before staff were able to safely exit. Mr Elsamin was monitored every 15 mins thereafter and he variously moved around the room, sat on the bed, and lay on a mattress on the floor. At about 8:50 pm, nursing staff were preparing to remove Mr Elsamin from the seclusion room when it was realised that he was not breathing.
A Code Blue medical emergency was called, and CPR was commenced. However, despite extensive resuscitation efforts, Mr Elsamin could not be revived, and he was declared deceased at 9.53 pm.
The coroner concluded that Mr Elsamin’s management whilst he was an involuntary patient at JHC was reasonable, when considered in the context of the resources available to his clinical team at the relevant time. I also accept that there were no practical alternatives which would have enabled Mr Elsamin to have been safely managed in the community. However, the coroner concluded that the supervision, treatment and care during Mr Elsamin received could not be said to have been optimal. The coroner emphasised that this observation was not a criticism of Mr Elsamin’s clinical staff at JHC, but rather a recognition of the circumstances Mr Elsamin found himself in.
Catch Words : Treatment resistant schizophrenia : Intellectual disability : Proclivity to violence : Open
Last updated: 14 August 2025