Coroner's Court of Western Australia

Inquest into the Death of Melanie Reanna TREGONNING

Inquest into the Death of Melanie Reanna TREGONNING

Delivered on :24 May 2019

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :Yes


I recommend the Honourable Minister for Health give priority to commissioning a Mental Health Observation Area at Fiona Stanley Hospital Emergency Department

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased at the time of her death the deceased was suffering from anxiety and depression. She was 31 years old.

The deceased was a talented illustrator who became overwhelmed with anxiety and depression. She sought help for her mental health issues from several different health professionals in the 48 hours leading up to her death.

On 11 May 2014 the deceased self-presented to the emergency department of St John of God Hospital in Murdoch. She mentioned her medications were not doing anything for her and intended to speak to her doctor. She then told the nurse that she intended to go home. The nurse contact the deceased’s father and advised him that the deceased had left the hospital. The deceased’s father rang her mobile and the deceased told her father she was at the beach in Fremantle. She was asked to come home, which she did.

Later that day the deceased and her parents went to the deceased’s brother’s house for a Mother’s Day lunch. The deceased was reluctant to attend and was noted to be quiet during the visit but this was not unusual so they were not overly concerned.

On 12 May 2014 the deceased was at home with her parents. She was watching television when her behaviour became concerning. Her parents drove her to Sir Charles Gairdner Hospital to see her doctor. The deceased spoke with her doctor on the telephone who referred the deceased to a general practitioner in order to obtain a psychologist referral. The deceased saw a GP but was unable to get an appointment to see a psychologist on the day, so returned home. The deceased later in the afternoon returned to the general practitioner’s surgery and saw another general practitioner. A decision was made to send the deceased to the Fremantle Hospital via an ambulance transfer to be assessed by a psychiatrist.

The deceased arrived at the emergency department of Fremantle Hospital and a Triage Assessment Form was filled out by a nurse. The deceased was seen by a resident medical officer. Discussions and enquiries were made with Alma Street Clinic to take the deceased’s referral but due to a miscommunication and absence of a psychiatric liaison nurse, no psychiatric assessment was performed. The deceased presented at Alma Street Clinic reception just prior to 7.00 pm on 12 May 2014. Staff identified that the deceased’s residential address was in the catchment area for the Mills Street Centre at Bentley Hospital, and not Alma Street.

The deceased was given a choice to stay and be assessed by a nurse that evening at Alma Street Clinic or self present the next day to Mills Street Centre. The deceased reported she was planning to attend work the following day and she had plans.

After leaving the hospital the deceased went home and told her parents she was going to sleep out in the studio/shed, which did from time to time. The next morning the deceased’s father went out to check on her and found her to be lying in a pool of blood near the door with wounds to her body and it was apparent she had died.

The Coroner made a recommendation for those reviewing the mental health service to provide a focus at public hospitals on ways of ensuring mental health emergencies are treated as seriously as any other medical emergency, with appropriate resources directed to ensuring that they are treated by properly trained staff in appropriate therapeutic environments.

Catch Words : Mental Health Observation Areas : Emergency Departments : Communication :


Last updated: 31-May-2019

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