Inquest into the Death of Roll, Robert
Deceased
Roll, Robert
Demographics
75y, male
Date of death
2009-07
Finding date
2013
Cause of death
Unascertainable due to advanced decomposition; likely lung cancer
AI-generated summary
Robert Roll, a 75-year-old socially isolated pensioner with terminal lung cancer, discharged himself from Royal Perth Hospital on 6 July 2009 against planned palliative care arrangements. Although Silver Chain Hospice arranged home visits, he refused assistance after becoming paranoid, possibly from alcohol effects or early dementia. Silver Chain notified the hospital they were withdrawing care, but Royal Perth Hospital did not follow up or arrange alternative monitoring. The deceased died alone in his rented unit between late July and October 2009, remaining undiscovered until July 2011. Key clinical failures included: lack of contingency planning when community care was refused; absence of follow-up by the hospital palliative team after Silver Chain withdrawal; failure to involve housing authority or conduct welfare checks despite clear vulnerability markers (unpaid utilities, uncollected mail); and no systematic communication between hospital, hospice, and housing services. The coroner emphasised the need for hospital social work departments to establish effective referral systems with contingency plans for patients who refuse services.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Self-discharge from hospital before care arrangements finalised
- Refusal of Silver Chain hospice assistance
- Possible paranoid delusions or alcohol-related cognitive impairment
- Lack of follow-up by Royal Perth Hospital palliative team after Silver Chain withdrawal
- Failure of referral process from hospital social work to Mercy Community Aged Care
- Housing Authority failure to conduct mandatory annual inspections
- Absence of welfare check procedures triggered by utility disconnections or unpaid bills
- Lack of communication between hospital, hospice, and housing services
- Social isolation and withdrawal from community supports
- No systematic contingency planning for patients refusing community care
Coroner's recommendations
- Hospital social work departments should establish effective systems of referral to community service providers with clear lines of communication
- These systems should include contingency plans for instances where patients are unwilling to accept community services or where services are disrupted
- Contingency plans might provide for arranging welfare checks by police or Department of Housing officers, identifying which agency is responsible for contact
- Department of Housing should consider implementing welfare checks triggered by markers such as unpaid water bills and uncollected mail for vulnerable tenants
- Department of Housing may wish to implement a process of requesting standard consent from tenants for welfare checks in nominated circumstances
- Utility providers should notify Department of Housing of unpaid bills by tenants to alert of possible need for welfare checks (though coroner noted this not yet implemented due to cost-benefit analysis)
- Community support service providers should be encouraged to notify Department of Housing if support is reduced or discontinued, subject to tenant consent
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —