Coroner's Court of Western Australia

Inquest into the Death of Aileen Helen QUARTERMAINE

Inquest into the Death of Aileen Helen QUARTERMAINE

Delivered on :22 March 2018

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased’s body was found in her home on 26 July 2014. It was believed she had died as a result of the effects of a fire either that same day or sometime during the evening before.  At the time of her death the deceased was being managed as a voluntary patient by the Kalgoorlie Community Mental Health Service, although she had been an involuntary patient in the past.  The deceased had a long history of schizophrenia/schizoaffective disorder with frequent relapses and was on regular antipsychotic medication.

On 25 July 2014 the deceased argued with her son and left his home. On the same day the deceased attended at the local IGA supermarket where she was a regular customer.  The deceased was abusive to staff and was evicted from the store.  Later that afternoon the deceased’s son went to the deceased’s home to check on her.  He found she was acting strangely, could not talk properly and was shaking.  The deceased’s son attempted to convince the deceased that she should go to hospital but he was unsuccessful.  He decided that he would have to seek help to arrange for the deceased to be taken to the hospital for assessment.

Despite the deceased’s son taking appropriate steps to alert both the police and the deceased’s mental health team of her deteriorating mental state, his calls for help were not successful.

The inquest focused primarily on the events that occurred the day preceding the discovery of her death, and the involvement of the various agencies at that time, as well as what circumstances could be ascertained about when and how the deceased died.

The Coroner was advised that since the deceased’s death the roles of the agencies involved on the day prior to her death have instituted actions to address individual staff failings and considered changes to systems and procedures.

The Coroner found the deceased died on or about 26 July 2014 at her home as a result of the effects of fire in a woman with alcohol effect and made an open finding as to the manner of death.

Catch Words : Mental health training for WA Police : Communication between hospital staff : Open Finding

Last updated: 30-Apr-2019

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