Inquest into the Death of Joyce Gladis CLARKE
Deceased
CLARKE, JOYCE GLADIS
Demographics
29y, female
Date of death
2019-09-17
Finding date
2025-06-09
Cause of death
gunshot wound to the abdomen
AI-generated summary
29-year-old Aboriginal woman (JC) of Ngarlawangga Yamatji Martu descent died from a gunshot wound inflicted by police on 17 September 2019. Four days prior, she was appropriately discharged from Sir Charles Gairdner Hospital following involuntary mental health admission for drug-induced psychosis; acute symptoms had resolved. The discharge was clinically sound with community follow-up arranged. Clinical lessons: (1) Importance of communicating discharge information between mental health services when vulnerable Aboriginal patients return to regional areas; (2) Recognition that recently discharged psychiatric patients remain at high risk, particularly those experiencing homelessness; (3) Value of mental health co-response models for police engaging with persons in mental health crisis; (4) Importance of cultural competency and de-escalation approaches in mental health assessment. The coroner found the death preventable through improved police de-escalation and team communication, not clinical error. Health services performed appropriately; inter-agency coordination could improve.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Recent discharge from involuntary mental health care without documented referral to local community mental health service
- Homelessness and lack of stable accommodation following release from prison
- Substance use (methamphetamine and cannabis) at time of incident
- Mental health vulnerabilities including schizophrenia history, antisocial personality disorder, and likely foetal alcohol spectrum disorder
- Inadequate police de-escalation tactics, communication failures between police officers, and failure to maintain safe distance from armed person
Coroner's recommendations
- Consideration be given to establishing a dedicated section or branch of WA Police for improving relations with Aboriginal persons, in consultation with Aboriginal communities
- WA Police oversee Aboriginal Cultural Awareness training to be co-designed with and delivered by Aboriginal persons, including face-to-face training on a regular basis, tailored to region, emphasising intergenerational trauma and foetal alcohol spectrum disorder
- De-briefing of six identified police officers regarding the incident by appropriate trainer, including discussion of de-escalation and cordon/containment, with scenario-based training from this incident incorporated into ongoing WA Police In-Service Critical Skills training
- WA Police continue trialling and considering the future use of new conducted energy weapon platforms such as tasers
- Health service providers prioritise engagement in development of Implementation Plan for Gayaa Dhuwi (Proud Spirit) Declaration to support culturally safe and responsive health care
- With patient consent, discharging health service provider consider notifying local health service when patient returning to Country or area where they habitually reside, even if no active referral to local service needed
- Director General of Department of Health consult with WA Police to work on sharing relevant mental health information between agencies while balancing privacy with imminent safety risks
- Mental Health Co-Response continues to be funded and model revisited to explore ways authorised mental health practitioner may provide support and advice to police at incidents involving mental health crisis
- WA Police consider review of In-Service Critical Skills training (levels 1, 2, 3, and 5) to assess integration of Use of Force training with effective communication training and to review effectiveness of audit processes
Full text
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