Coroner's Court of Western Australia

Inquest into the Death of Peter James WILSON

Inquest into the Death of Peter James WILSON

Delivered on : 26 June 2024

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : No

Orders/Rules : No

Suppression Order : N/A

Summary : Mr Peter James Wilson (Mr Wilson) died on 1 November 2021 at Fiona Stanley Hospital from the effects of fire, after dousing himself with boat fuel and setting himself alight.  He was 41-years of age.

Mr Wilson had a complex mental health history with an atypical presentation, and a history of polysubstance use including alcohol, cannabis and methylamphetamine.  His first recorded interaction with mental health services occurred in 2000, when he was admitted to Joondalup Health Campus (JHC) and diagnosed with a manic episode with psychotic features and polysubstance use.

During his mental health journey, Mr Wilson received various diagnoses, including bipolar affective disorder, psychosis, schizophrenia, schizoaffective disorder, personality disorder, and obsessive compulsive disorder.  He had been trialled on various psychotropic medications, and he frequently complained of side effects relating to the medications was prescribed.

Mr Wilson had a history of non-compliance with his medication regime, and he was known to unilaterally alter prescribed doses without seeking medical advice.  Mr Wilson had various periods of engagement with his local community mental health service (Service), and he was although he had a number of inpatient admissions, he did not like being admitted to JHC, on the basis of what he perceived were suboptimal clinical experiences.

On 27 August 2021, Mr Wilson presented to JHC after ingesting drain cleaner.  Mr Wilson gave conflicting accounts as to why he had done so, including that this was an attempt to take his life, and that he was trying to treat his constipation.  After being stabilised, Mr Wilson was admitted to Sir Charles Gairdner Hospital (SCGH) where his injuries were treated.  After assessment by the psychiatric team, Mr Wilson was transferred to Graylands Hospital (Graylands) until his discharge home on 18 September 2021.

On 14 October 2021, Mr Wilson’s mother contacted the Service to requested an urgent review as she and her former husband had become very concerned about Mr Wilson’s welfare, and were unable to manage his level of risk at home.  After assessment, Mr Wilson agreed to be admitted to the Mental Health Observation Area at SCGH, where he remained until 15 October 2021, when he was transferred to Graylands.

During his admission to Graylands, Mr Wilson’s treating psychiatrist formed the clinical opinion that Mr Wilson had a major mental health illness, which was either schizophrenia or schizoaffective disorder bipolar type.  Mr Wilson was commenced on a long-lasting depot injection of paliperidone, a medication he had been successfully treated with in the past.  Mr Wilson was discharged from Graylands under a community treatment order (CTO) on Friday, 29 October 2021.

Following his discharge, Mr Wilson reportedly experienced side effects relating to his medication, including a tremor and restlessness, although there is no evidence that Mr Wilson was experiencing any thoughts of suicide or self-harm, or that he was exhibiting any signs he was at acute risk of self-harm in the period between his discharge and his death.

The coroner found that although Mr Wilson’s discharge from Graylands on 29 October 2021 was justified, Mr Wilson’s discharge plan was compromised.  That was because prior to Mr Wilson’s discharge, his consultant psychiatrist at Graylands did not speak directly with the consultant psychiatrist at the Service who would be assuming Mr Wilson’s care in the community.  The coroner noted that since Mr Wilson’s death, relevant clinical staff have been reminded of the policy requirement that all patient discharges involving a CTO require: “verbal consultation between associated Consultant Psychiatrists” before the patient is discharged.

The coroner also noted that Mr Wilson’s discharge summary from Graylands (which contained important information about the management of his mental health) was not sent to the Service on the day Mr Wilson was discharged.  It was also regrettable that neither Mr Wilson nor his mother were provided with basic information about Mr Wilson’s diagnosis of schizophrenia, or his medication regime, including the depot injections of paliperidone he had recently been started on.

The coroner found that notwithstanding their familiarity with the mental health system, Mr Wilson and his mother should also have been given information about the likely, or potential side effects of Mr Wilson’s medication, and concerning signs and symptoms to watch out for, as well as the pathway back to care should Mr Wilson’s mental state deteriorate.

At about 10.30 am on 1 November 2021, Mr Wilson was dropped off at his father’s home for a visit.  After they went out and did some shopping, Mr Wilson’s father made them some lunch, and they watched a movie on TV.  At some point, Mr Wilson went outside for a cigarette, and whilst his father went inside to put some music on, Mr Wilson went into the garage and doused himself with fuel from a jerry can labelled “boat fuel”, before setting himself alight.

Mr Wilson was taken to JHC by ambulance, and after being stabilised, he was transferred to Fiona Stanley Hospital and admitted to the intensive care unit, where he underwent various specialist reviews.  It was determined that Mr Wilson’s injuries were non-survivable.  Mr Wilson was kept comfortable until he died at 6.58 pm on 1 November 2021.

After carefully considering the available evidence, and having regard to the relevant principles, the coroner was unable to conclude (to the relevant standard) that any defect in Mr Wilson’s discharge planning was causative of his death.

Catch Words : Community Treatment Order : Chronic mental health illness : Atypical presentation : Suicide


Last updated: 19-Aug-2024

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