Inquest into the Death of Samaan Salah Tilmiz ELSAMIN
Deceased
Samaan Salah Tilmiz Elsamin
Demographics
21y, male
Date of death
2022-11-09
Finding date
2025-07-22
Cause of death
unascertained
AI-generated summary
Samaan Salah Tilmiz Elsamin, a 21-year-old with treatment-resistant schizophrenia, moderate-to-severe intellectual disability (IQ 57), and unpredictable violent behavior, died on 9 November 2022 at Joondalup Health Campus while under an Involuntary Treatment Order. He was placed in seclusion due to escalating agitation and found unresponsive approximately one hour later. Despite extensive post-mortem investigation, no definitive cause of death could be determined. The coroner found his care was reasonable given available resources, but identified several system gaps impacting safety: difficulty visualizing patient respirations during seclusion observation, unclear allocation of nursing responsibility, inconsistent CPR assessment protocols, and incomplete resuscitation documentation. The primary barrier to optimal care was absence of specialized facilities for patients with his complex constellation of severe mental illness, intellectual disability, and challenging behavioral needs.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- severe treatment-resistant schizophrenia
- moderate to severe intellectual disability
- unpredictable and violent behavior
- limited verbal skills limiting behavioral assessment
- difficulty identifying behavioral triggers
- restraint and seclusion during acute agitation
- observational gaps during seclusion monitoring
- shared responsibility for observation impacting continuity of assessment
- absence of specialized mental health facilities for complex needs
- inadequate NDIS funding for community support
Coroner's recommendations
- Ensure facilities such as Secure Recovery and Rehabilitation Units (SRRU) are developed and made available for patients with complex mental illness, intellectual disability, and challenging behavioral needs
- Improve facility design and monitoring systems to enable clear visualization of patient respiration during seclusion observation
- Establish clear allocation and continuity of responsibility for nursing observation of secluded patients
- Implement consistent CPR assessment and technique protocols in accordance with Australian Resuscitation Council guidelines
- Ensure complete and accurate documentation of resuscitation procedures and clinical responses
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