Coroner's Court of Western Australia

Inquest into the Death of Frances May Cooper

Delivered on 30 November 2015 at Perth.

Finding of Coroner King.


The deceased was an involuntary patient under the Mental Health Act 1996 at the time of her death. She had been diagnosed with chronic paranoid schizophrenia.

On the morning of 30 October 2011 the deceased was a patient in the mental health unit at Kalgoorlie Regional Hospital. The deceased went on an escorted smoke break to an area outside the hospital carpark and returned without any problem. She then went on an unescorted smoke break at about 11:25am and did not return.

A search of the carpark area for her was unsuccessful.

At about 1pm the deceased’s body was found beside a nearby train line. She had sustained a non-survivable head injury, apparently from being struck by part of a train which had passed by at midday.

The Coroner was satisfied that the standard of supervision, treatment and care of the deceased while an involuntary patient in October 2011 was unsatisfactory due to a lack of formal risk assessments, a lack of a multidisciplinary team, lack of collaboration with the deceased’s family and a lack of a secure place at the hospital for mental health patients to smoke at the time when smoking on Health Department property was prohibited.

The Coroner noted that these failures were systemic or environmental, in the sense that hospital staff managed the deceased within the environment existing at the time.

The Coroner was satisfied that the hospital had since implemented steps to address those failures.

The Coroner found that the deceased died on 30 October 2011 at a railway line near the intersection of Charlotte Street and St Albans Road in Piccadilly from head injury.

The Coroner was not able to determine whether the deceased intended to be struck by the train or whether she was struck by accident, so made an open finding as to how death occurred.

Catch Words

Mental Illness : Involuntary Patient : Absconding : Department of Health Smoking Policy : Head Injury : Train : Open Finding.

Last updated: 10 August 2022

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