Coroner's Court of Western Australia

Inquest into the Death of Theodore Herbert Eric JOHANSEN

Inquest into the Death of Theodore Herbert Eric JOHANSEN

Delivered on :10 September 2018

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was discovered by police in the water behind his home in Pinjarra late in the morning on 29 October 2014. The evidence indicated he had deliberately entered the water sometime late in the evening of 28 October 2014 or in the early hours of the morning on 29 October 2014.  The deceased was 50 years of age.

The deceased had experienced difficult family issues both as a child and as an adult and had been treated for anxiety and depression. However, despite a history of depression, he had no previous history of self-harming behaviour or suicidal thoughts.

On 28 October 2014 the deceased presented to his GP practice in crisis and admitted to having suicidal thoughts and a plan. Due to concerns for his safety he was transferred by ambulance to Peel Health Campus for psychiatric assessment.  He was reviewed by an ED doctor and then referred to a Psychiatric Liaison Nurse (PLN) for more in-depth risk assessment.  After consultation with the deceased, a diagnosis was made that he was experiencing a situational crisis which had been resolved.  The deceased denied any current thoughts of suicide and appeared satisfied with a proposed management plan that involved actions he could take in the community.  He had indicated that he was not seeking a voluntary admission and it was not felt at the time that this was required.  There was no clear reason to admit him under the Mental Health Act.

It was not disclosed to the health professionals who assessed the deceased that he had a family history of mental illness and suicide. He had also declined to allow the staff to speak to his family or other sources to gain more information about his background.  This left the professionals with missing key pieces of information in their risk assessment that may have changed the pathway they followed.

The Coroner was satisfied that the PLN and doctor who assessed the deceased had appreciated that there was an increased risk that the deceased might harm himself, given his admitted plan and the fact that he was seeking help. However, they were reassured by the deceased’s behaviour and demeanour in the ED and the responses that he gave, which made them consider his risk was no longer acute.  However, this also underscores the difficult situation in which the deceased’s wife and family were placed, who could be told little about what had occurred.

Catch Words : Psychiatric Liaison Nurse : Mental state and risk assessments : Powers to place patients on involuntary forms : Suicide Intent : Family history of mental illness : Suicide.

Last updated: 30-Apr-2019

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