Coroner's Court of Western Australia

Inquest into the Death of Lorna May WOODS

Inquest into the Death of Lorna May WOODS

Delivered on : 12 March 2019

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : At the time of her death, the deceased was 39 years of age and was an involuntary patient under the Mental Health Act 2014 (WA).

The deceased had a difficult childhood and began drinking alcohol and using illicit drugs when she was 13 years of age. In 1997, she was diagnosed with disorganised schizophrenia and found to have an IQ of 64, which is generally regarded as a mild intellectual impairment. She had an extensive history of minor public order type offences but in 2013, she spent 100 days at the Frankland Centre, Graylands Hospital pursuant to a hospital order issued under the Criminal Law (Mentally Impaired Accused) Act 1996 for assaulting a public officer and stealing offences.

The deceased had a history of presenting at hospital for treatment, often following to alleged assaults, and either leaving before she was seen, or discharging herself against medical advice. In April 2015, she presented to hospital with a serious kidney infection and discharged herself despite being told she risked serious illness or death if her condition was not treated.

On 7 January 2017, the deceased complained of nausea and stomach pain and was taken to the emergency department at Joondalup Health Campus. She was diagnosed with sepsis and found to have metastatic ovarian cancer. Scans also identified her shrunken left kidney as the possible source of her sepsis. The deceased was reviewed by the gynaecology team and found to be agitated and thought disordered and a psychiatric review was requested.

On 9 January 2017, a psychiatrist found the deceased to be thought disordered and suffering from a psychotic illness made worse by delirium. She was placed on an inpatient treatment order under the Mental Health Act 2014 (WA) on the basis that she was unable to make decisions for herself and required urgent medical treatment.

In the afternoon of 9 January 2017, the deceased’s condition deteriorated and despite the efforts of clinical staff, she developed septic shock from which she was unable to recover. Her family were at the deceased’s bedside when she died in the early hours of 10 January 2017.

The Coroner noted that the deceased had a complex medical and mental health history and that on numerous occasions, the deceased had not taken up offers of treatment and support. The deceased lacked insight into her health issues and had a limited understanding of the need for treatment and follow-up.

Having regard to all of the evidence, the Coroner found that the supervision, treatment and care provided to the deceased while she was an involuntary patient at Joondalup Health Campus was both reasonable and appropriate.

Catch Words : Inpatient Treatment Order: Mentally Impaired: Natural Causes

Last updated: 30-Apr-2019

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