Inquest into the Death of Andrew John KEY
Deceased
Andrew John KEY
Demographics
49y, male
Date of death
2015-08-11
Finding date
2020-11-04
Cause of death
incised injury to the neck
AI-generated summary
Andrew Key, a 49-year-old man with bipolar affective disorder, died by suicide on 11 August 2015 after self-inflicting a neck injury while being restrained by police. Clinical lessons emerged regarding mental health assessment and crisis response. On 5 August, psychiatric assessment in ED correctly followed the Mental Health Act in declining involuntary admission, though the independent expert noted hindsight benefits of admission. On 6-7 August, clinical decisions to manage Mr Key in the community were appropriate given his variable mental state and expressed willingness to engage. Critical failure occurred on 10 August when police call-taker failed to create a dispatch task after Mr Key's mother reported suicidal ideation and relapse, falling below service standards. The coroner emphasised the importance of clinicians directly contacting police rather than relying on family members, and highlighted the benefits of mental health co-response teams in improving information flow to police and call-takers.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- relapse of bipolar affective disorder
- non-compliance with antipsychotic medication
- fluctuating mental state
- failure of police call-taker to create dispatch task on 10 August 2015
- failure of police call-taker to recognise risk factors and suicidality indicators
- lack of direct communication between clinicians and police
- absence of mental health co-response team at the time
Coroner's recommendations
- That the Mental Health Co-Response continue to be funded, and that consideration be given to providing the Western Australia Police Force and the Western Australia Mental Health Commission with additional, external funding in order to support expansion of the programme in a way that meets demand.
- That consideration be given to providing the Western Australia Police Force and the Western Australia Mental Health Commission with additional, external funding in order to support the expansion of the Mental Health Co-Response in metropolitan areas of Perth.
- That work continue on the planning of the Mental Health Co-Response in regional areas of the State, and consideration be given to providing the Western Australia Police Force and the Western Australia Mental Health Commission with additional, external funding in order to support the expansion of the Mental Health Co-Response into regional areas.
Full text
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