Coroner's Court of Western Australia

Inquest into the Death of Richard Anthony BOROS

Inquest into the Death of Richard Anthony BOROS

Delivered on :17 May 2024

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 14 January 2021, Richard Anthony Boros (Mr Boros) died in the mental health assessment unit (MHAU) at Fiona Stanley Hospital (FSH) from an upper airway obstruction (choking). He was 50 years old. At the time of his death Mr Boros was an involuntary patient under the provisions of the Mental Health Act 2014 (WA). Consequently, an inquest into his death was mandatory as he was a person held in care.

Mr Boros had a long-standing mental health condition which was diagnosed as paranoid schizophrenia. After an extended stay at Graylands Hospital, he was discharged to assisted living accommodation in May 2020. Despite initial good progress with the management of his schizophrenia, Mr Boros had an increase in his paranoia and agitation. By the end of 2020, he had become non- compliant with his medication. 

At about 4.00 am on 14 January 2021, Mr Boros was located by police on the bridge at Canning Train Station. He was threatening to jump and was extremely paranoid, stating that people were out to get him. After an extended period of negotiations, police officers were able to grab Mr Boros and he was taken to FSH.

At the ED of FSH, Mr Boros was assessed as being at high risk to himself. He was admitted to the MHAU at about 1.10 pm where he was allocated a room with one bed and an ensuite bathroom. After an assessment by the MHAU consultant psychiatrist, Mr Boros was placed under an inpatient treatment order with visual observations by nursing staff to be completed every 15 minutes. 

The Coroner was satisfied that nursing staff did not undertake the visual observations that had been specified. Although he was seen on several occasions by nursing staff between 4.00 pm and 6.53 pm, Mr Boros was not sighted by anyone when he was in his room with the door closed from 6.53 pm until 8.24 pm, when a nurse entered his room to perform a visual observation. The nurse found Mr Boros unresponsive in his bathroom with a wad of tissue paper blocking his airway. Despite extensive resuscitative efforts by FSH staff, Mr Boros could not be revived.  

The Coroner found that the extended period of over 90 minutes when Mr Boros was not subject to any visual observations was a significant oversight. The Coroner also found that the situation was made worse by misleading entries in Mr Boros’ observation chart that had been completed by two nurses. These entries recorded he had been visually observed every half hour from 4.30 pm. CCTV footage clearly established that this was not the case.

The Coroner was satisfied of the changes that had been made at FSH since Mr Boros’ death. These changes have been designed to overcome the deficiencies in Mr Boros’ case that existed for his visual observations and the entries in his observation chart.

Catch Words : Involuntary Patient : Psychiatric Treatment : Quality of Supervision, Treatment and Care : Inadequate Observations by Nursing Staff: Misleading Recordkeeping by Nursing Staff: Suicide

Last updated: 7-Jun-2024

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