Coroner's Court of Western Australia

Inquest into the Death of Carole LIVESEY

Inquest into the Suspected Death of Carole LIVESEY

Delivered on :25 January 2022

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Ms Livesey was last seen alive on 3 October 2017 after absconding from Rockingham General Hospital. She had been admitted as an Involuntary Patient to the hospital on 8 September 2017 with a diagnosis of anorexia nervosa and depression and on a background of a recent suicide attempt. Ms Livesey had a long history of disordered eating and excessive exercise routine and she was regarded as a high-risk of suicide or self-harm. While in hospital, Ms Livesey was not compliant with eating meals or taking nutritional supplements prescribed to her. On 21 September 2017 it was decided she required a nasogastric tube to be inserted to administer feeds. The tube was inserted two days later, on 23 September 2017, and Ms Livesey was confined to a wheelchair to stop her exercising. She showed good progress in weight gain from that time, and her last weight, as recorded the morning of her absconding, showed she was almost at the weight set that would allow her to be discharged. However, Ms Livesey was reportedly unhappy with her weight gain and the goal weight set.

Ms Livesey had been moved from a closed ward to an open ward, and then granted leave to go with a nurse to the kiosk. On 3 October 2017, Ms Livesey expressed an interest in going on the escorted group walk around the grounds of the hospital. Her request was granted, and she was given allowed by staff to go into the grounds in a wheelchair with a nurse, although it was somewhat unclear if permission was obtained from a doctor first.

Ms Livesey was sitting in the wheelchair and being pushed by an agency assistant nurse when she suddenly got up and fled the group. One of the staff escorting the patients ran after her and tried to call her back, but Ms Livesey continued running until she was out of sight. The hospital management were notified and an absconding alert was raised at 10.15 am. Police received and absconding report at about 11.10 am, indicating Ms Livesey was a high-risk mental health absconder. Police officers went to her house, but there was no sign that Ms Livesey had been home.

At 12.47 pm that same day, Ms Livesey was brought in by a member of the public to the Rockingham Salvation Army. She had been found her near the beach and was soaking wet. The Salvation Army staff formed the impression that Ms Livesey had deliberately walked into the water and was possibly suicidal. She was still wearing a hospital band, so the hospital were contacted by a member of the Salvation Army to advise that Ms Livesey was there. The hospital staff indicated they would contact police to collect Ms Livesey. The staff and volunteers at the Salvation Army provided Ms Livesey with dry clothes and food and tried to keep her occupied while they waited for the police to arrive. Unfortunately, the attendance of police was delayed due to resourcing issues, and Ms Livesey soon became suspicious and restless and indicated she wanted to leave. At 2.24 pm, Ms Livesey left the Salvation Army facility. Two volunteers followed her for a short period, in the hope that police would arrive and they could direct them to her whereabouts, but eventually they gave up. Ms Livesey was last seen by one of the volunteers walking down the street away from the Salvation Army. This was the last time Ms Livesey was seen alive and there has been no confirmed sighting of her since, although there were some reports she may have been seen in the area over the next day or two by various members of the public.

The inquest was held to determine whether Ms Livesey’s suspected death could be confirmed to the requisite standard. Another focus point of the inquest was the time taken for police to attend and collect Ms Livesey. It was established that the delay was due to the lack of police cars being available at the time as they were assigned to other matters. This issue was extensively reviewed at the inquest and it was indicated that WA Police are considering making changes to the WA Police Manual and there are possible changes to the absconder form at the South Metropolitan Health Service, to improve communication in future similar cases.

After reviewing all the evidence, the Deputy State Coroner concluded she was satisfied Ms Livesey is deceased. The manner of Ms Livesey’s death was left open.

Catch Words : Missing Person : Involuntary Patient : Absconding : Open Finding

Last updated: 21-Mar-2022

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