Inquest into the Death of Quoc Xuan TRAN
Deceased
Quoc Xuan TRAN
Demographics
36y, male
Date of death
2019-04-10
Finding date
2022-08-17
Cause of death
Immersion (drowning)
AI-generated summary
Quoc Xuan Tran, a 36-year-old man with schizoaffective disorder and autism spectrum disorder, died by drowning in the Swan River on 10 April 2019. He was subject to a Community Treatment Order and had experienced repeated housing instability over 30 months, being evicted five times. Despite proactive case management efforts to secure appropriate accommodation, Mr Tran was resistant to alternatives and expressed attachment to hostel living. He presented to the ED on 8 April 2019 with accommodation concerns; staff conducted a risk assessment documented as non-urgent with no acute mental health issues identified. The coroner found appropriate clinical care was delivered within available resources, but identified critical system-level deficits: a severe lack of suitable supported accommodation services for people with chronic mental illness and complex behavioural needs. The coroner recommended urgent development of Secure Extended Care Units and Community Care Units to address this gap.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- chronic housing instability and repeated evictions
- lack of suitable supported accommodation for people with complex mental health needs
- limited rehabilitation services and transitional care units
- patient resistance to alternative accommodation despite proactive case management
- lack of insight into mental illness
- possible suicide related to homelessness distress
Coroner's recommendations
- The East Metropolitan Health Service should strongly lobby and encourage the Mental Health Commission to use its best endeavours to ensure that the planned Secure Extended Care Units and the Community Care Units are operational as soon as practicable.
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