Coroner's Court of Western Australia

Inquest into the Death of Lewis Henry Mark WESTON

Inquest into the Death of Lewis Henry Mark WESTON

Delivered on : 12 December 2022

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : Yes

In order to enhance patient care, the Department of Health introduces, with appropriate safeguards to protect patient confidentiality, a reciprocal sharing of information between its clinical information database (PSOLIS) and the clinical databases of NGOs that provide mental health services to the community.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Lewis Weston died on 3 November 2020 at Higgins Park in East Victoria Park, from ligature compression of the neck. He was 22 years old. At the time of Mr Weston’s death, he was subject to a Community Treatment Order (CTO). 

In 2014, Mr Weston was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). He was prescribed dexamphetamine and his ADHD responded well to that treatment. Mr Weston was also using cannabis and the psychiatrist who was treating the ADHD emphasised the need for Mr Weston to monitor his cannabis use carefully. By mid-2017, Mr Weston’s self-care had deteriorated, and he was not sleeping well due to university exam stress. He had also increased his use of cannabis and ADHD medication. On 24 June 2017, Mr Weston attended the emergency department at Sir Charles Gairdner Hospital. He was diagnosed with experiencing psychosis. He would not accept that he was unwell, and he had to be sedated after he refused to remain in hospital. Mr Weston was admitted to Graylands Hospital on the same day, where he remained until his discharge on 5 July 2017. He required further treatment in Graylands Hospital in December 2018.  On 4 January 2019, his treating psychiatrist saw Mr Weston who presented as speaking rapidly, being elevated in mood and having grandiose beliefs that he had a special purpose. He lacked insight into his illness and maintained he was not unwell.  As Mr Weston was refusing to take his antipsychotic medication, there was no option other than to place him on a CTO.

Mr Weston had a further relapse with psychosis when he started using cannabis again. On 16 April 2019, he was admitted to Sir Charles Gairdner Hospital where he was placed into a locked ward of the mental health unit under the Mental Health Act 2014. He was discharged on 14 May 2019 under another CTO. The CTO was for a period of three months; however, on 11 June 2019, Mr Weston’s treating psychiatrist cancelled his CTO on the basis that he had the mental capacity to manage his conditions. Shortly after that, Mr Weston ceased engaging with his treating psychiatrist and stopped taking his medication. However, Mr Weston’s family reported that his mental health was good and that he was able to achieve high distinction grades in his end of year university examinations. However, Mr Weston had another relapse in December 2019.

On 30 December 2019, Mr Weston was taken to the emergency department at Sir Charles Gairdner Hospital. After being assessed, Mr Weston was admitted into hospital where he stayed until his discharge on 17 February 2020 when he was placed under a third CTO. This CTO was for a period of three months and was due to end on 16 May 2020. On 12 May 2020, Mr Weston’s treating psychiatrist continued his CTO for a further three months until 15 August 2020. On 11 August 2020, Mr Weston’s treating psychiatrist deemed the continuation of the CTO was necessary, and a further three months was extended for the CTO until 14 November 2020. The extensions of the third CTO were because of Mr Weston’s refusal to accept he required antipsychotic medication.

In October 2020, Mr Weston’s CTO was transferred to another mental health service provider due to a change of his residential address.  Mr Weston had very limited contact with his new provider before his death the next month.

The Coroner found the supervision, treatment and care provided to Mr Weston by his treating mental health service providers during all three CTOs was appropriate.

The Coroner made a recommendation directed towards improving information sharing between the Department of Health and NGOs that provide mental health services.

Catch Words : CTO : Non-Compliance : Supervision, Treatment and Care : Sharing of Information : Recommendation : Suicide

Last updated: 2-Oct-2023

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