Coroner's Court of Western Australia

Inquest into the Death of Laureen Kaye REILLY

Inquest into the Death of Laureen Kaye REILLY

Delivered on :27 March 2020

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Laureen Reilly was found deceased in her room at BP Luxury Care in Maddington on 3 May 2022. Ms Reilly was on a Community Treatment Order (CTO) under the Mental Health Act 2014 (WA) at the time of her death, so an inquest into her death was mandatory.

Ms Reilly had a long history of mental health concerns and illicit drug use. Her most recent psychiatric diagnosis was schizophrenia and she had also been diagnosed with an acquired brain injury with frontal lobe syndrome and cognitive impairment, which was likely attributable at least in part to a head injury she sustained as a child. Ms Reilly had a number of involuntary inpatient admissions and was managed on CTO’s in the community, but once she transitioned to being a voluntary patient, she would generally be lost to follow up as there was no mandatory requirement to engage.

On 24 March 2021, police attended the caravan park where Ms Reilly was living for an unrelated purpose. While at the park, residents asked the police officers to check on Ms Reilly as they could smell gas. The officers broke into her caravan and found Ms Reilly on the floor with the LPG gas stove running. Ambulance officers were called to attend and Ms Reilly was taken by ambulance to Arnadale Hospital. She initially denied any suicidal intent, but later admitted she had opened the gas tap with the intention of ending her life.

Ms Reilly apparently had some outstanding charges and she was brought before the Magistrates Court on 27 April 2021. She was unable to engage meaningfully with court staff and was placed on a hospital order. She was transferred to the Frankland Centre for psychiatric treatment. Ms Reilly remained paranoid and thought disordered while in the Frankland Centre, and it was established that she had not been compliant with her anti-psychotic depot medication since November 2021. She was recommenced on the depot. Ms Reilly was eventually granted bail on 12 May 2021, with a condition that she comply with her psychiatric treatment. She was transferred back to Armadale Hospital that day. Ms Reilly remained as an involuntary patient at the hospital until mid-June 2021, when she began to show improvement following electro-convulsive therapy.

Ms Reilly had an appointed guardian and her finances were managed by the Public Trustee. When it became apparent that she was ready for release, her guardian consulted with her NDIS support worker to find accommodation for her in the community. Eventually she was released on a CTO so that she would receive her depot anti-psychotic medication every fortnight and she was placed at the BP Luxury Care facility in Maddington. It is a privately run low care facility that accommodates residents with mental health conditions. Ms Reilly’s mental health care was managed by the Eudoria St Clinic, including her regular depot injections, and staff at BP Luxury Care assisted with administering her oral medications daily. Ms Reilly showed little insight into her mental illness and expressed a strong desire to come off the CTO and move from BP Luxury Care to Busselton in order to be closer to family. However, with encouragement she continued to engage with her treatment and remain living at the facility. The continuation of her CTO was confirmed by the Mental Health Tribunal on 10 December 2021.

Ms Reilly received her last depot injection on 20 April 2024. She saw her care coordinator at the clinic on 29 April 2022 and showed no evidence of thought disorder or psychotic symptoms.

Ms Reilly was last seen at her residence on 1 May 2022 by a support worker when she was given her morning medication. Staff looked for her on 2 May 2022 but she was not in her room and her housemates reported she had not returned home. The next day, being 3 May 2022, facility staff were advised Ms Reilly was due to have her next depot injection. Staff went looking for her and eventually identified that the television was on in her room, which indicated she had returned since staff last checked the previous afternoon. When she did not respond to knocking, a staff member obtained a key and got permission to enter her room. He found her unresponsive on the floor of her room. Ambulance officers attended and confirmed she had died. Illicit drug paraphernalia was found in her room and testing of some of the materials identified that Ms Reilly had been in possession of heroin.

A post mortem examination established Ms Reilly died as a result of combined drug toxicity, with indicators she had injected heroin prior to her death.

The Coroner was satisfied beyond all reasonable doubt Ms Reilly died as a result of combined drug toxicity and that her death occurred by way of accident.

The Coroner was satisfied Ms Reilly received regular and consistent mental health treatment whilst on her CTO and that her overall supervision, treatment and care was of a high standard.

Catch Words : CTO : Combined Drug Toxicity : Accident

Last updated: 16-Apr-2024

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