Inquest into the Death of Joseph Charles ABELA

Contributing factors

• Failure to place on Community Treatment Order despite clear indications
• Failure to administer prescribed depot antipsychotic medication
• Inadequate liaison between prison and community mental health services
• Substandard risk assessment after 6 October 2021 home visit
• Failure to conduct planned follow-up home visit
• Inadequate mental health service policies for management of violent/aggressive consumers
• Incomplete clinical documentation and records
• Lack of consultation with judicial officers regarding Form 1A status at bail hearings
• Limited bed availability at Frankland Centre secure forensic facility
• Patient's chronic lack of insight into mental illness and persistent non-compliance with medication
• Patient's polysubstance use and disengagement from services

Coroner's recommendations

1. The Department of Justice should amend relevant policies to ensure that when a prisoner who is being held on remand and is the subject of a Form 1A under the Mental Health Act 2014 (WA) appears before any court in relation to an application for bail or sentence, the presiding judicial officer is made aware of the existence of the Form 1A and the options available to the Court in dealing with that prisoner
2. In order to ensure that the mental health of prisoners can be more effectively managed, the Department of Justice should seek approval from State Forensic Mental Health Services for all psychiatrists and mental health clinicians employed by the Department to have read-only access to PSOLIS (Psychiatric Services Online Information System)
3. The Department of Justice and the Department of Health should confer and identify and implement strategies to ensure the effective management of the mental health of persons admitted to prison whilst the subject of a Community Treatment Order made under the Mental Health Act 2014 (WA), who are subsequently released