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Coroners Act, 1996 [Section 26(1)]

Western

Australia

RECORD OF INVESTIGATION OF DEATH

Ref No: 14/05

I, Evelyn Felicia Vicker SM., Deputy State Coroner, having investigated the death of Jessica Mary DEWHURST with an Inquest, held at the Perth Coroner's Court, Level 10, May Holman Centre, 32 St George's Terrace, Perth on 3 June 2005 find the identity of the deceased person was Jessica Mary DEWHURST and that death occurred on 27 May 2003 at Room 2, Secure Ward, Swan Adult Mental Health Services, Middle Swan as the result of Ligature Compression of the Neck in the following circumstances:

The deceased was 20 years of age having been born on 6 December 1982. She was one of four children whose parents had separated when she was 8 years of age. She had remained mainly in the care of her mother although she had a good and close relationship with her father.

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BACKGROUND After the separation of her parents the deceased's mother remarried and had another two children. maintained a good relationship. It appears the deceased, her siblings and the two new children all The deceased completed her schooling in Mandurah to Year 10 and then lived with her father for Year 11 at Lynwood. She did not complete her schooling and returned to Mandurah to live with her mother, and completed a hospitality course at TAFE. The deceased moved to Perth and lived with her

grandparents in Bentley while working at the Carousel Shopping Centre. She commenced a relationship with a boyfriend whose family ultimately decided to move to Melbourne. The deceased at that time appeared to get on well with her boyfriend's family and she moved to Melbourne with the family who paid for her air ticket. This was not successful and she returned to Perth a short time later. She was 17 years of age and this dispute with her boyfriend's family considerably lowered her self-esteem. The deceased then obtained a job at a well-known restaurant and returned to live with her grandparents. Anxiety associated with this job caused her considerable stress, as did travelling to and from her work. Her grandmother found her accommodation closer to the location of the restaurant. Her landlady had a son who also

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lived at the accommodation. than the deceased.

He was considerably older

Unfortunately she entered into a

relationship with this man, which in addition to her low self-esteem, proved to be extremely destructive to a young vulnerable female. The deceased's family noted she was becoming increasingly depressed in addition to which she appears to have been exposed to drugs which she then abused. This appears to have been the beginning of several admissions to mental health facilities with respect to the deceased. Community Health Services The first record of the deceased seeking assistance appears in July 2001 when she was referred to the Peel Community Health Services, as a result of her relationship difficulties. However, by October 2001, while still only 18 years of age, she contacted the Peel Community Mental Health Services asking for assistance. She was assessed in November 2001 as presenting with features consistent with a mild major depressive episode on a background of borderline These were personality traits. She denied suicidal ideation at that time but did admit to past self-harm attempts. outcome. described as impulsive and with a low likelihood of serious Gradually her admission to suicidal ideation increased and in January 2002 she expressed a death wish. She was commenced on Fluoxetine 20mg mane.

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From 24 - 28 April 2002 she was admitted to the Peel Health Campus and discharged to the Community Health Services as an outpatient. She was not particularly compliant with her management plan. She was admitted to Sir Charles Gairdner Hospital (SCGH) from 7 May 2002 until 28 June 2002 after presenting to the Emergency Department in a distressed state. interventions were tried. It was determined this was a psychotic episode and various She was discharged to her mother's care but continued to have relationship concerns. On 13 August 2002 she was again admitted to SCGH with suicidal thoughts. She remained in SCGH until 22 August 2002 when as a result of her absconding from the ward and obtaining heroin she was transferred to Graylands Hospital. At Graylands Hospital she was assessed by Dr Ford, and maintained there under the provisions of the Mental Health Act. She was diagnosed as suffering from a protracted depressive reaction in the context of stressors due to her relationship difficulties, borderline personality tendencies and substance abuse. During this time her relationship with the older man terminated and she was released to her mother's care on 18 September 2002. She at that stage said she had no more suicidal thoughts and felt well.

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After her return to live with her mother in Mandurah the deceased met her new boyfriend, Antony Lappel. She remained with her mother until her birthday on 6 December 2002, at which stage she began to live with her boyfriend in Morley. She was no longer employed and was living on unemployment benefits while trying to find a job. Her boyfriend indicated in his statement to the court he was unaware of the deceased's difficulties when he first met her, however, during the course of the relationship he found out about her past. It was his view most of her problems stemmed from her treatment from her prior boyfriend. He realised she suffered depression and psychotic episodes which could result in her becoming very paranoid. Mr Lappel reports he felt it was difficult to leave the deceased by herself because of her difficulties, and as far as he was concerned she did not drink a lot or use drugs excessively. In late March 2003, Mr Lappel reports the deceased felt she was not coping and realised she needed to get back to hospital. She presented at SCGH on 29 March 2003 where she remained until 8 April 2003. auditory hallucinations. She is recorded by the hospital as complaining of depression, suicidal ideation and She discharged herself against She was medicated with medical advise with a diagnosis of substance induced mood disorder and psychotic features. Risperidone, Venlafaxine, Coloxyl and Senna with multi

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vitamins. boyfriend.

She was to be followed up by the Morley

Community Services as she was residing in Morley with her

After only 12-days the deceased re-presented at the Emergency Department at SCGH complaining of on-going hallucinations and paranoid thoughts. She was acutely suicidal and felt unsafe in an open ward. Consequently she was transferred to the Swan Adult Mental Health Centre on 2 May 2003 as an involuntary patient under the provisions of the Mental Health Act. Prior to transfer she had required one on one special nursing while attempts were made to find her suitable accommodation. She was visited by her boyfriend when he was able, but she was only allowed hour long visits for the first two weeks. After her transfer to a general ward she was able to go out under supervision. Swan Adult Mental Health Centre The deceased was admitted as an involuntary patient on 3 May 2003 when she was assessed by the Duty Consultant, Dr Molin. She gave a self-history of several instances of suicidal behaviour including heroin overdose and lying on train tracks. Once she had stabilised she was transferred to a general ward, however, remained very disturbed. She was placed in the general ward on 19 May 2003 with 30-minute observations for substance abuse, absconding and sexual

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vulnerability. This time it was determined she would need involuntary status until at least July 2003. The deceased had frequent contact with her father by way of telephone and her boyfriend. Her father visited her about three or four times a week and the deceased described to him she felt as though she was being punished as a result of the supervision regime. She did not believe it was helping her recuperate. It is a sad fact the tension between a safe environment and a therapeutic environment for people suffering mental illness is a dilemma for their treating practitioners. A safe environment is generally so unnatural it exacerbates a patient's harm. On 3 May 2003 the deceased was agitated and distressed as a result of a lack of sleep. She became paranoid and She wished to go on exhibited disordered thoughts. of her parents. The deceased clearly wished to be with her boyfriend and on the 25 May 2003 she absconded from her ward in the company of another patient from Swan Adult Mental Health Centre. It appears she spent the time at the Midland feelings of un-wellness, while a therapeutic environment will always give them some options for self-

weekend access but was denied this unless in the company

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Junction Hotel, and rang her boyfriend from the hotel, inebriated. Staff from the Swan Adult Mental Health Centre also traced the deceased by her mobile telephone and she informed them she was going to go home and not return to hospital. She was recorded as "absent without leave" and her consultant notified. The deceased's boyfriend reports when she contacted him he had also been drinking and was unable to go and collect her from Midland. He suggested she take a taxi to their home which she did. The deceased spent the night with her boyfriend and during that time her mother also contacted them to ask her daughter to notify the hospital of her welfare. The following morning she rang the hospital and said she would be returning that day. Her boyfriend dropped her at the hospital about midday on his way to work. She was assessed by Dr Smith as to her mental status. On her return Dr Smith's notes indicate she became very agitated and started to make illogical comments, and pull her hair out. Due to her presentation she was transferred back to a secure ward. She became very distressed when

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another patient in the secure ward assaulted a member of the nursing staff. She was medicated and reviewed by Dr Graham later in the afternoon of 26 May 2003. At that stage she seemed to have settled a little and claimed her distressed state had been due to discussing her ex-boyfriend with her current boyfriend. She stated she felt restricted by the secure ward and she wanted additional counselling. She believed she had been brain washed by her previous boyfriend. She felt she was paranoid and was receiving auditory commands through the television. She denied substance abuse and this would seem to be supported by a drug screen and the fact her current boyfriend was reasonably concerned to control her drug taking realising it was of concern. She spoke to her mother during the course of the afternoon and expressed some concern with being restricted again in hospital. Ward staff found the deceased generally settled on the ward with one of two periods of agitation depending on situations arising in the ward. Later she was given Temazepam at 11:30pm to help her sleep and then went to have a cigarette. While she was in the courtyard having her cigarette she spoke with her father on the telephone and also her boyfriend. Both her father and her boyfriend thought she sounded positive and was

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optimistic about being released from the hospital in the future. She told her father she was handling things well and that she would see him the following Wednesday. The deceased was seen in the courtyard at 12:15am in the early hours of 27 May 2003 as part of her 30minute observation plan. She was later seen by the shift coordinator for the morning, Psychiatric Nurse, Wesley Elliott. It was 12:20am and she was seen walking from the courtyard back to her room, room 2. At 12:30am her room was checked as part of the observation plan. The en-suite door was closed indicating engaged. Mr Elliott returned 10 minutes later for her check but could not find her in the main bedroom, nor did he get a response when he called out her name. and entered. Once inside he found the deceased hanging by her neck from one of the shower taps with a cloth sash looped around the tap and around her neck. He freed her but could not locate a pulse or breathing. A general emergency was called and resuscitation attempts commenced until she was declared life extinct at 1:20am on 27 May 2003. He noted the ensuite light was on and the door closed again, he knocked

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POST MORTEM REPORT The post mortem examination of the deceased was undertaken by Dr Clive Cooke, Chief Forensic Pathologist at the state mortuary. Dr Cooke found there was a ligature mark around the deceased's neck consistent with the ligature, but no internal neck injury. There was no evidence of any other type of trauma to the deceased and Dr Cooke was satisfied she had died as a result of ligature compression of the neck and no other person had been involved in her death. Her toxicological analysis was consistent with therapeutic levels of her medication.

CONCLUSION DECEASED

AS

TO

THE

DEATH

OF

THE

I am satisfied the deceased was a young emotionally vulnerable female who had suffered periods of substance abuse as the result of traumatic and abusive personal relationships outside her family. As a result she developed a drug induced mood disorder with psychosis and auditory hallucinations. While she developed a more supportive relationship at the conclusion of 2002, she still relapsed from time to time with feelings of depression. It is clear from the papers her family

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were as supportive as they were able to be and no one appears to have been able to determine how to best help the deceased through her difficulties. She was made an involuntary patient under the Mental Health Act 1996 on 3 May 2003 and transferred to Swan Adult Mental Health Centre in an attempt to stabilise her mood disorders. The tension between a safe environment and a therapeutic environment seems to have been one the deceased found extremely difficult to cope with. On 25 May 2003 she absconded to spend time with her boyfriend and later returned to the health centre on 26 May 2003. There she was reassessed and found to be extremely vulnerable and as a consequence, was moved to a more safe environment in a secure ward. Unfortunately, the deceased found this extremely restrictive and although she appeared to be coping when contacted by her parents and boyfriend, it is apparent she was subject to impulsive actions. Under her observation plan she was last seen alive at 12:20am after having a cigarette in the ward courtyard. When she was checked at 12:30am the door to her ensuite was closed but due to privacy concerns she was not rechecked until 12:40am. I do not believe on the information available the deceased made a plan intending to take her life but I am of the view

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once she retired for the night in the early hours of 27 May 2003 some impulse over took her to end her life which she could not control. Unfortunately she found a means to do this by way of a sash and the fixtures in her ensuite. She was discovered at 12:40am in the ensuite hanging from a shower tap. unsuccessful. I find the death occurred by way of Suicide. Resuscitation was commenced but was

COMMENTS ON THE SUPERVISION TREATMENT AND CARE OF THE DECEASED

I note the father of the deceased expressed a number of concerns with the supervision of the deceased in that she was known to suffer suicidal ideation and yet had managed to find the means by which to commit suicide while in a secure ward. While I am completely sympathetic to the family of the deceased with respect to these issues, I am acutely aware of the tension between a safe environment and a therapeutic environment. The safe environment appears to have been part of the deceased's problem with being in a facility in the

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first place and it is quite likely a more secure environment would have exacerbated the situation. At times, when there were high concerns for the deceased, she was placed on "one on one specials" but remained in as comfortable an environment as possible. As far as possible fixtures and fittings in the secure ward are as safe as possible while still providing inmates with some level of human comfort. Consequently, there will always be anchor points for ligatures and clothing/bedclothes will always provide a ligature. At the time of her death the deceased was fragile but had returned to the hospital after a period of absconding. She spoke with both her parents and her boyfriend, all persons with whom she appeared to be secure about their feelings for her. None of those persons detected a plan to commit suicide and she did express future orientations. In view of this I do not believe there was more which could have been done with respect to her supervision, treatment and care without causing her unnecessary distress. It is my impression the deceased's suicide was entirely impulsive in that on her return to her room she had some thought or impulse which she was unable to control and resulted in her death. This was a very tragic outcome for one so young and well loved.

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In all the circumstances involving the deceased I find her supervision, treatment and care was adequate.

EF VICKER SM., DEPUTY STATE CORONER 30 June 2005

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