Inquest into the Deaths of Heather GLENDINNING and Jessica Rose CUZENS and Jane Lesley margaret CUZENS
Deceased
Heather GLENDINNING and Jessica Rose CUZENS and Jane Lesley margaret CUZENS
Demographics
46y, female
Date of death
2011-12-05
Finding date
2016-07-21
Cause of death
Ms Glendinning: multiple sharp force injuries (suicide); Jane Cuzens: multiple injuries (homicide); Jessica Cuzens: multiple sharp force injuries (homicide)
AI-generated summary
This tragic case involved a mother with severe untreated psychosis who killed her two daughters and then herself. Ms Glendinning had a longstanding history of paranoid delusions, cannabis use, and mental health difficulties dating back to 2000. Over the decade preceding her death, multiple agencies—mental health services, police, child protection, and the Family Court—had contact with her but failed to recognize the full extent of her deteriorating psychiatric condition. Key problems included: fragmented information sharing between agencies; Ms Glendinning's reluctance to engage with mental health services due to fear of prejudicing her custody case; her ability to appear rational when motivated; absence of a psychiatric assessment despite a Family Court judge requesting one in 2008; and lack of coordination in late 2011 when her mental state was clearly collapsing. The coroner concluded that while the deaths were difficult to predict, the Family Court, child protection, and mental health systems should have shared information more proactively and should provide clearer pathways for psychiatric assessment in custody disputes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- severe untreated psychosis and paranoid delusions
- cannabis abuse
- sleep deprivation
- prolonged stress from family court proceedings
- lack of information sharing between agencies
- patient reluctance to engage with mental health services due to fear of custody implications
- failure to implement psychiatric assessment ordered by judge in 2008
- failure of mental health triage service to follow up in 2010
- inability of agencies to access complete clinical picture
Coroner's recommendations
- That the Department of Child Protection and Family Services and the Family Court of Western Australia, including independent children's lawyers, develop and implement a procedure to share proactively, where appropriate, information relevant to the health and safety of children the subject of custody disputes.
- That the Family Court of Western Australia provide litigants in custody disputes with information indicating how mental illness may be considered by the Court.
- That steps be taken by Government to ensure so far as practicable that judges of the Family Court are able to obtain psychiatric reports when required to determine the best interests of children the subject of custody disputes.
- The coroner encouraged (but did not formally recommend) Government to work towards providing appropriate independent counselling to children the subject of custody disputes in the Family Court, including provision of independent information about court orders.
- The coroner noted that as funding for mental health services in regional areas becomes available, a single-point triage model should be considered.
- The coroner encouraged public health authorities to bring to the community's attention that cannabis use can have dire psychological consequences.
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