Inquest into the Deaths of Jessica Rose CUZENS and Jane Lesley Margaret CUZENS and Heather GLENDINNING
Deceased
Jessica Rose CUZENS and Jane Lesley Margaret CUZENS and Heather GLENDINNING
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 Lesley Margaret Cuzens: multiple injuries (homicide); Jessica Rose Cuzens: multiple sharp force injuries (homicide)
AI-generated summary
Heather Glendinning, severely mentally ill with chronic paranoid delusions exacerbated by cannabis abuse and stress from family court proceedings, killed her daughters Jane and Jessica on 5 December 2011, then took her own life. While multiple agencies encountered Ms Glendinning—mental health services, police, her GP, and family court—critical information was not shared between them. She was unwilling to engage with mental health professionals, fearing disclosure would be used against her in custody disputes, and masked her psychotic symptoms when assessed. Mental health clinicians who evaluated her (psychologist, nurse, psychologist) did not recognise psychotic illness, and no single clinician had complete information. The coroner found that agencies acted reasonably given fragmented information and Ms Glendinning's non-engagement, but identified systemic failures: lack of proactive information-sharing between child protection and family court; absence of psychiatric assessment powers in family court proceedings; and regional mental health service limitations. Key opportunities to intervene—a court-ordered psychiatric assessment in 2008 and police referral in 2010—were not realised.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
severe mental illness with chronic paranoid delusions and psychosis
cannabis abuse
sleep deprivation
prolonged stress from family court proceedings
unwillingness to engage with mental health services due to fear of use in custody dispute
ability to mask mental health symptoms and appear rational
lack of information sharing between agencies
incomplete information available to individual clinicians
regional mental health service limitations
absence of psychiatric assessment powers in family court
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.
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