Inquest into the Death of Stephen Kenneth RYAN

Inquest into the Death of Stephen Kenneth RYAN

Delivered on :13 April 2016

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary :  The deceased was at the time of his death a 62 year old man with a long history of significant mental illness.  For most of his life he lived in New South Wales, however, he made his way to Perth 18 months prior to his death.  On 23 December 2012 the deceased was taken by police to hospital after he was found walking along a busy road attempting to stop drivers to seek assistance.  He was initially admitted at Royal Perth Hospital and then later transferred to Bentley Health Service on 28 December 2012.  The deceased was subject to an involuntary patient order under the Mental Health Act 1996

The deceased’s psychiatric care was managed by a consultant psychiatrist who noted that the deceased’s psychiatric illness caused him to experience chronic paranoid and grandiose delusions.  The deceased was treated with psychiatric medication which was only partially effective in treating his symptoms due to the fact that whilst in hospital the deceased often refused to take his medication as prescribed, as he did not acknowledge he had a psychiatric illness and was in need of care.

In addition the deceased was also physically unwell during his admission.  He was a heavy cigarette smoker throughout his adult life which had led to the development of chronic obstructive pulmonary disease.  The deceased continued to smoke and frequently refused to take medication such as prescribed antibiotics or inhaled steroids to treat his chronic lung condition.  On four occasions the deceased’s condition deteriorated and he was admitted to Royal Perth Hospital for treatment of type II respiratory failure.  These admissions were complicated by his aggression, agitation and refusal to comply with treatment prescribed by physicians.  Due to the deceased’s health deterioration he was unable to travel back to New South Wales to be with his family.  Instructions were given to the hospital for the deceased’s care and in the event of a significant physical health deterioration, active resuscitation should not be attempted.

On the evening of 12 August 2013 the deceased was noted to be having difficulty walking and his breathing was shallow and laboured.  He was given some oxygen to assist his breathing.  While hospital staff were in his room the deceased quickly became non-responsive and was attended to by nursing staff and the duty medical officer.  In keeping with his family’s wishes, active cardiopulmonary resuscitation measures were not commenced and he died.

The Coroner found that the deceased died on 12 August 2013 as a result of bronchopneumonia on background of chronic obstructive pulmonary disease and found the deceased died of natural causes.

The Coroner was satisfied that the deceased was given a high standard of care whilst at the Bentley Hospital and that his death was anticipated due to the ongoing progression of his lung disease.  The Coroner found that efforts were made to keep the deceased as comfortable as possible during his final decline, while still managing his psychiatric symptoms.

Catch Words : Involuntary Patient : Psychiatric Care : Non-Resuscitation : Natural Causes

Last updated: 4-Jun-2024

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