WAcommunity

Inquest into the death of Jaxon Charles Kinnane

Deceased

Jaxon Charles Kinnane

Demographics

22y, male

Coroner

Coroner Urquhart

Date of death

2020-10-12

Finding date

2024-12-06

Cause of death

Immersion in water (drowning) in a man with combined drug effect

AI-generated summary

Jaxon Charles Kinnane, 22, drowned in the Swan River on 12 October 2020. He had chronic schizophrenia with persistent delusional beliefs (microchip in ear) and was a polysubstance user, particularly methylamphetamine. He received treatment in Casuarina Prison, the Frankland Centre, and St John of God Midland Hospital. While clinicians provided appropriate care within constraints of mental health law and his voluntary patient status, several missed opportunities were identified: Dr M. did not request prison records (EcHO), did not discuss paliperidone depot injections despite previous effectiveness, and ordered an MRI that experts considered therapeutically inadvisable. A critical gap occurred when his father warned nursing staff of deterioration on 8 October but this was not documented or communicated to Dr M.. The coroner identified that lack of Community Treatment Order provisions in prisons prevented continuity when he was unexpectedly released from custody.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatrycorrectional healthgeneral practice

Error types

communicationsystemdiagnostic

Drugs involved

paliperidonequetiapinesertralineamitriptylinenortriptylinelorazepamclonazepammethamphetamineamphetaminedextroamphetamine

Clinical conditions

schizophreniapsychosisdelusional disordermethamphetamine-induced psychosisattention deficit hyperactivity disorderobsessive disorderpost-traumatic stress disorderantisocial personality disordercluster B personality disordersubstance use disorderpolysubstance abuse

Procedures

MRI scanappendectomyurine drug screen

Contributing factors

Chronic psychosis with persistent delusional beliefs
Methamphetamine and amphetamine use (recreational levels at time of death)
Antidepressant medication interaction with stimulants (risk of serotonin syndrome)
Lack of effective psychiatric supervision upon community release
Unexpected release from custody without Community Treatment Order
Poor medication compliance and lack of insight into mental illness
Failure to maintain psychiatric continuity of care between prison and community settings

Coroner's recommendations

Office of the Chief Psychiatrist should undertake an assessment of the use of Community Treatment Orders within the prison setting to enable better management of prisoners with serious mental health conditions who refuse established effective treatments and are at risk of deterioration
Implementation of three prior recommendations by Coroner Jenkin regarding: (1) judicial awareness of Form 1A applications for prisoners; (2) read-only PSOLIS access for Department of Justice psychiatrists; (3) strategies for effective management of CTOs for persons subsequently released from prison

Full text

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Source and disclaimer

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