Coroner's Court of Western Australia

Inquest into the Death of David GRIEVE

Inquest into the Death of David GRIEVE

Delivered on :6 September 2018

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased had a long history of psychotic illness and at the time of his death was an involuntary patient at Graylands Hospital. His illness had resulted in multiple hospital admissions over the years, many of them at Graylands Hospital.  He had also developed multiple co-morbidities including obesity, hypertension and type 2 diabetes, that increased his risk of cardiovascular disease.  He was 45 years of age.

The inquest focused primarily on the medical care provided to the deceased in the weeks prior to his death, both physical and mental, as well as the events surrounding his death. The deceased’s family had expressed some concern about the failure to diagnosis the deceased’s heart related issues prior to his death.  These concerns were addressed at the inquest hearing by an expert medical witness.

The deceased first began to suffer from psychotic symptoms when he was 17 years old. This led to his first admission to Graylands Hospital in 1987.  Between 1987 and 1988 the deceased had more than 20 admissions to Graylands Hospital.  He was initially diagnosed with schizophreniform psychosis but in 1988 his diagnosis was changed to schizophrenia.  The deceased’s admissions to Graylands for his psychotic relapses were often precipitated by alcohol and marijuana abuse or non-compliance with his medications.  Due to his non-compliance with oral medications he was managed with depot injections for many years.

Prior to his death the deceased was living with his best friend and brother in a rental property. All of them had mental health issues.  They were very supportive of each other and were generally self-sufficient and received good family support.  The deceased usually attended the Odin Road Medical Centre in Innaloo for his regular medical care and was in the care of the Osborne Park Community Mental Health Service with regard to his mental health issues.

In the days prior to his death the deceased spoke to his mother and told her he had been in hospital to get his heart checked as he was experiencing breathlessness. He advised her that he had an appointment to see a heart specialist.  It became apparent to the deceased’s mother that he was deteriorating mentally around this time and she felt that he seemed more aggressive towards her and his friend, which was not his nature.

On 25 August 2015 the deceased’s mother contacted the Mental Health Emergency Response Line with concerns that the deceased was not well. In response the deceased was assessed that afternoon and found to be hostile, over inclusive and pressured in speech.  He admitted to hearing voices on a regular basis but denied that they were causing him distress.  The deceased was reviewed again the following day and it was not felt that there were enough grounds to admit him as an involuntary patient.  On 29 August 2015 the deceased refused to allow Hospital in the Home staff to visit.  Osborne Clinic staff assessed the deceased on 31 August 2015 and he was reported to be hostile and threatening.  He was transferred to Graylands with the assistance of police under the Mental Health Act so that he could be psychiatrically assessed.

On 1 September 2015 the deceased was noted to be restless and disorganised during the night and his sleep chart indicated he had been awake from 1.00 am, despite having been given a sleeping tablet. A nursing entry at 11.20am reported the deceased had been elevated and inappropriate towards female staff.  The deceased was reviewed by a Consultant Psychiatrist who made the deceased an involuntary patient.  The deceased was transferred to a segregated secure ward just after 1.00 pm, where he remained psychotic and agitated.  At 10.00 pm the deceased was noted to be sleeping in a chair in the common lounge area of the ward, with his breath being regular, deep and snoring.  At 10.45 pm the deceased’s breathing was reported to become slower and he was seen to slide from the chair.

A medical emergency was activated and when the Duty Medical Officer arrived the deceased appeared to be pale and cyanotic. Resuscitation attempts were unsuccessful and he died.

The Coroner found the deceased died as a result of natural causes relating to his heart disease. The Coroner concluded the medical care leading up to the deceased’s death and his supervision, treatment and care were reasonable and appropriate in the circumstances.

Catch Words : Involuntary Patient : Multiple Co-morbidities : Heart Disease : Natural Causes.


Last updated: 30-Apr-2019

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