Coroner's Court of Western Australia

Inquest into the Death of Stephen Craig SOLLY

Inquest into the Death of Stephen Craig SOLLY


Delivered on : 8 March 2021

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Solly died from respiratory failure on 11 March 2018. He was 63-years of age.

At the time of his death, Mr Solly was subject to an inpatient treatment order under the Mental Health Act 2014 (WA) at Graylands Hospital (GH). He had been diagnosed with paranoid schizophrenia and organic personality disorder and more recently with cognitive impairment, which was assessed as early onset dementia.

In 2015, Mr Solly was diagnosed with emphysema and pulmonary fibrosis related to smoking. He reportedly smoked 30 cigarettes daily and despite being advised to quit, he declined to do so. In late 2016, a CT scan of Mr Solly’s chest showed a new lesion in his lower right lung and also confirmed widespread emphysema, stable interstitial lung disease and nodules in his right and left lungs. Despite his severely limited lung function, Mr Solly continued to smoke heavily and he adamantly refused to stop smoking, despite frequently succumbing to respiratory failure. Mr Solly’s psychiatric and cognitive issues meant that it was extremely difficult for the respiratory team to engage him in discussions about treatment options. Oxygen therapy, which would have helped Mr Solly’s symptoms, was not a viable option because he refused to stop smoking and his aggressive behaviour meant that an oxygen cylinder would have posed an unacceptable risk on a closed ward at GH.

At a meeting on 26 December 2016, that was attended by Mr Solly, his treating team and members of his family, it was decided that in view of Mr Solly’s physical condition and his mental illness, further treatment should be directed to improving the quality of his life.

Mr Solly was admitted to Sir Charles Gairdner Hospital (SCGH) with pneumonia and exacerbation of his lung disease on two occasions in 2017 and for the last time on 2 February 2018, after an episode of severe breathless. A CT scan at that time showed that the size of Mr Solly’s lung mass had increased, suggesting a malignancy. Mr Solly declined any active treatment and continued to smoke, although he accepted medications such as prednisolone, antibiotics and puffers.

As Mr Solly’s physical condition declined, his behaviour became more challenging and he assaulted patients and staff in February and March 2018 and threw milk over a consultant psychiatrist during a review. A resuscitation directive was discussed with his family and a series of ‘Not for CPR’ forms were prepared.

After he was woken by staff on 11 March 2018, Mr Solly came out of his room shouting and threw mile at the nursing station on his ward. Although he allowed his vital signs to be taken at about 9.00 am he refused a subsequent request and lay on the floor in front of the nursing station demanding cigarettes. At about 10.0 am, Mr Solly allowed himself to be helped into a wheelchair and it was noted that his breathing was laboured. As nursing staff tried to record his vital signs, he suddenly lost consciousness. A medical emergency was activated and at 10.20 am, Mr Solly was declared deceased.

The coroner found Mr Solly had received a very good level of care at both SCGH and GH and made no recommendations. On the basis of the evidence before him, the coroner found death occurred by way of Natural Causes.

Catch Words : Death in Care : Involuntary Patient: Natural Causes

Last updated: 30-Mar-2021

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