Coroner's Court of Western Australia

Inquest into the Death of Peter Jonathon Rex BOLTON

Inquest into the Death of Peter Jonathon Rex BOLTON

Delivered on : 28 August 2024

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 20 November 2022, Peter Jonathon Rex Bolton (Mr Bolton) died from ligature compression of the neck (hanging) when he was a patient in the locked mental health ward at St John of God Midland Hospital (SJOGMH). He was 36 years old. At the time of his death, Mr Bolton was an involuntary patient under the provisions of the Mental Health Act 2014 (WA) and an inquest into his death was mandatory as he was a person held in care.   

Mr Bolton had a long history of involvement with mental health services. He had been diagnosed with various psychiatric conditions including schizophrenia, schizoaffective disorder, drug-induced psychosis and organic personality disorder (arising from a traumatic brain injury he sustained as a child). He had difficulty regulating his emotions and had frequent episodes of violence and impulsivity.  Mr Bolton also had a history of self-harming behaviours.

On 5 January 2022, Mr Bolton deliberately ran into oncoming traffic and was struck by a car. He was taken by ambulance to the ED at SJOGMH. On 7 January 2022, Mr Bolton was admitted to the locked ward at SJOGMH as an involuntary patient after he admitted to being suicidal. Despite repeated efforts by his treating team to have him safely discharged back into the community, Mr Bolton remained as an involuntary patient in that ward for over ten months.

On 20 November 2022, Mr Bolton was in his room. At 2.00 pm when nursing staff attended for his hourly observations, Mr Bolton was in the ensuite bathroom with the door closed. However, he answered appropriately when staff asked about his wellbeing and he was allowed to remain in the bathroom with the door remaining closed.

At 3.00 pm, Mr Bolton was not in his room and nursing staff saw a knot from a bed sheet protruding from the top of the closed door to the ensuite bathroom. When the door was opened, Mr Bolton was found slumped against the door with the bed sheet tied around his neck. He was unresponsive. Despite extensive resuscitation efforts, Mr Bolton could not be revived. 

Noting the difficulties in managing Mr Bolton’s complex mental health needs, the Coroner was satisfied that the supervision, treatment and care he had received at SJOGMH was of a high standard.

The Coroner was also satisfied with the improvements that had been made at SJOGMH since Mr Bolton’s death. These included the replacement of bedroom and ensuite doors in the locked ward with doors that have an alarm activated if pressure is applied to the top of the door, and changes to patient observations that now require a visual sighting of patients at all levels of observations.    

Catch Words : Involuntary Patient : Person Held in Care : Supervision, Treatment and Care : Suicide


Last updated: 19-Sep-2024

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