Coroner's Court of Western Australia

Inquest into the Death of Stephen Thomas OXLEY

Inquest into the Death of Stephen Thomas OXLEY

Delivered on :23 July 2019

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : At the time of his death the deceased was the subject of a community treatment order (CTO) made under the Mental Health Act 2014 (WA). The deceased was placed on a CTO because he had very little insight into, and impaired judgment with respect to, his mental illness. The deceased also lacked capacity to make sound treatment decisions with respect to his mental health.

The deceased’s first contact with mental health services occurred in 1989 and his mental health condition was managed by the Subiaco Adult Community Mental Health Clinic (Subiaco Clinic) for many years. When the deceased was compliant with his medication, his mental health was generally stable. The deceased’s last admission to a mental health facility as an in-patient occurred in 2014.

The deceased’s CTO was last extended on 25 October 2017 and was due to expire on 24 January 2018. The deceased had a number of risk factors for cardiovascular disease but the terms of the deceased’s CTO did not authorise staff at Subiaco Clinic to compel the deceased to undergo investigations such as blood tests and ECG’s that might have detected any deterioration in the his cardio-vascular health.

On 7 December 2017, the deceased’s mother visited him at his home with some shopping and stayed for about 30 minutes. The deceased did not mention any problems or issues and he seemed his normal self. On 9 December 2017, the deceased’s long-term neighbour saw him walking back to his house carrying some milk. He was walking slowly but there was nothing out of the ordinary about his appearance.

On the morning of 11 December 2017 the deceased’s mother received a call from one of his friends to say she had visited the deceased on each of the previous two days and there had been no response when she knocked on his door. The deceased’s mother went to the deceased’s home and found him lying on the floor next to his bed. Emergency services were called and ambulance officers confirmed the deceased had died.

The Coroner found the supervision, treatment and care that the deceased received from Subiaco Clinic while he was the subject of a CTO was of a very good standard.

The Coroner concluded that the deceased’s lifestyle choices played a significant role in his unexpected and premature death and found the deceased died of natural causes.

Catch Words : Community Treatment Order : Supervision, Treatment and Care : Natural Causes.

Last updated: 2-Aug-2019

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