Inquest into the death of Chloe HEUSTON

Contributing factors

• ambiguities in Mental Health Act 2007 regarding scheduling criteria
• unclear definition of 'serious harm' in mental health legislation
• lack of explicit inclusion of harm caused by mental illness itself as basis for scheduling
• lack of explicit inclusion of serious emotional harm to others as basis for scheduling
• untreated mental illness in perpetrator
• inadequate support and information available to families and carers regarding mental health threats

Coroner's recommendations

1. Amend Mental Health Act 2007 to expressly state that 'for the person's own protection from serious harm' should include harm caused by the mental illness itself
2. Amend Mental Health Act 2007 to expressly state that 'for the protection of others from serious harm' should include protection from serious emotional harm
3. Delete reference to physical harm in sections 15(a) and (b) and specify that protection from serious harm includes harm caused by mental illness itself and serious emotional harm to others
4. Ensure no ambiguity in Part 1(1) of Schedule 1 regarding the test that must be met before a patient is scheduled
5. NSW Health design and distribute an information booklet for families, carers and friends seeking to support persons with mental illness who have been threatened by or are fearful of a person who may be suffering from mental illness, including emphasis on availability of community treatment orders