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Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia

Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia

Inquest Findings

Home →Inquest Findings→Inquest Findings 2026→Walder, Travis John

Inquest into the Death of Travis John WALDER

Delivered on: 27 July 2026

Delivered at: Perth

Finding of: Brendyn Dean Nelson

Recommendations: Yes

Orders/Rules: No

Suppression Order: No

Recommendation No 1: The WA Country Health Service embed the parallel assessment model, and the practice of psychiatric liaison nurses proactively identifying and reviewing patients with known mental health histories and communicating relevant information to ED clinicians, into existing policies and procedures at Bunbury Regional Hospital.

Summary:

Travis John Walder was a 32-year-old man who died on 24 August 2023 after running in front of an oncoming passenger train at the Robertson Drive rail crossing in Picton, Western Australia. Travis had a history of schizophrenia, substance use disorder and previous mental health admissions. The Coroner determined that Travis died from multiple injuries and found that his death occurred by suicide.

The inquest examined Travis’s mental health care in the weeks before his death, including his discharge from the Acute Psychiatric Unit (APU), management by the Bunbury Community Mental Health Team, and presentation to Bunbury Regional Hospital the night before he died.

Although Travis was placed on a Community Treatment Order (CTO) on discharge, it lapsed due to an administrative error and was not formally confirmed within the required timeframe.

The Coroner found no individual clinical failures and no lawful basis to detain Travis when he left the Emergency Department. However, the inquest identified shortcomings in discharge planning and communication with Travis’s family, and recommended that improvements made since Travis’s death at Bunbury Regional Hospital be embedded into practice.

Catch Words: expired CTO, discretionary inquest, suicide.


Last updated: 6 August 2026

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