Coroner's Court of Western Australia

Inquest into the Death of Philip SULLEY

Inquest into the Death of Philip SULLEY

Delivered on :13 February 2023

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Philip Sulley (Mr Sulley) was 58 years old when he died on 27 April 2020 from coronary artery arteriosclerosis. He was a patient at the Bentley Mental Health Unit (BMHU), and at the time of his death he was an involuntary patient under the provisions of the Mental Health Act 2014 (WA). An inquest into his death was mandatory as he was a person held in care.

Mr Sulley was an electrician by trade. After ceasing work in about 2004, he received a disabilities support pension, and he was often homeless. From 2004 to 2013, Mr Sulley had a number of hospital admissions relating to his mental health. The principal diagnoses were drug-induced psychosis and paranoid schizophrenia.  

On 19 April 2020, Mr Sulley was taken by ambulance to the emergency department at Royal Perth Hospital (RPH) for a mental health assessment after he was behaving in an irrational manner at a CBD hotel that was housing at-risk homeless people following the outbreak of the COVID-19 pandemic.  He was reviewed by a psychiatry registrar and mental health nurse and discharged several hours later.

On 22 April 2020, Mr Sulley was again taken to RPH after he was behaving in an erratic and aggressive manner at a bus stop in Maylands. He remained in the emergency department overnight before he was taken to BMHU for a psychiatric review on 23 April 2020.

Mr Sulley remained in an agitated state when at BMHU. He refused to have a physical assessment and a blood sample taken, despite several requests over four days. Two attempts to conduct a psychiatric review were terminated due to Mr Sulley’s threatening behaviour. On 24 April 2020, the consultant psychiatrist at BMHU made an inpatient treatment order pursuant to section 55(1) of the  Mental Health Act 2014 (WA) and Mr Sulley became an involuntary patient. He was prescribed antipsychotic medication and pain relief medication when he complained of body pain.

At no time during his two brief stays at RPH or his admission at BMHU did Mr Sulley complain of symptoms suggesting a heart-related condition. Nor did his prior medical records indicate a history of any cardiac disease.

At about 1.20 pm on 27 April 2020, Mr Sulley was in the communal dining room in ward 6 at BMHU preparing a drink when he staggered backwards and fell to the floor. Medical staff immediately went to his assistance and saw that he had no respiratory rate and was not breathing. Despite CPR and doses of adrenaline, Mr Sulley remained unresponsive and a short time later a doctor certified he had died.

The Coroner was satisfied that based on the information they had, the psychiatry registrar and mental health nurse acted appropriately in discharging Mr Sulley from RPH on 19 April 2020. The Coroner was also satisfied that the supervision, treatment and care provided to Mr Sulley when he was at RPH on 22 and 23 April and at BMHU from 23 to 27 April 2020 was appropriate. Given Mr Sulley’s acute psychotic behaviour, the decision to make him an involuntary patient was entirely justified. The doses of antipsychotic medication he was prescribed were also appropriate, notwithstanding that this medication can increase the risk of cardiac arrythmias in a person with a pre-existing cardiac disease.

Catch Words : Mental Health: Involuntary Patient: Natural Causes

Last updated: 23-Feb-2023

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