Inquest into the Death of Ellery

Contributing factors

• Long-standing amphetamine abuse (8 years)
• Acute severe paranoia and psychotic symptoms
• Recent suicide attempts by suffocation and strangulation
• Depression and anxiety (diagnosed March 2007)
• Insomnia and poor nutritional intake
• Inability of triage nurse to place patient on mental health orders
• Failure of CERT to attend despite clear indication and available resources
• Police welfare check did not include mental health assessment
• Absence of security staff to prevent departing patient
• Lack of coordination and ownership between services regarding priority level assessment

Coroner's recommendations

1. Department of Health should, as a matter of priority, consider offering appropriately qualified nurses undertaking triage duties in mental health facilities the opportunity to become Authorised Mental Health Practitioners under the Mental Health Act 1996, so that they can place those who present at triage 'on forms' if the need arises.
2. Bentley Hospital and in particular the Mills Street Centre be provided with sufficient security staff so that staff security is enhanced and those 'on forms' can be prevented from leaving the hospital.
3. Department of Health and the WA Police Service work together to create an environment that will enable those suffering a mental health crisis receive speedy and efficient welfare checks. The parties should consider co-locating a Department of Health official at the police communications headquarters to assist in determining the priority of cases coming from mental health facilities or services.
4. Department of Health should, as a matter of priority, communicate to its employees engaged in triage and in CERT teams that a welfare check undertaken by the WA Police Service does not replace a thorough mental state examination conducted by senior mental health professionals.
5. Department of Health should, as a matter of priority, create and communicate to its staff working in triage and in CERT teams a clear policy which defines who has ownership of Response Level 1 matters and how and when that party should act to ensure that a request of the police to locate the consumer is made in a timely manner and in such a way as to ensure a priority response; in the event the police cannot undertake a welfare check in a timely manner, the policy should mandate the appropriate response CERT members should follow.
6. CERT officers, rather than the police, should, in all circumstances assess a consumer who has been placed at Response Levels 1, 2 and 3, unless by doing so CERT staff place themselves at risk by attending to a consumer who is armed, threatening or poses a threat to others. In those situations of danger CERT staff should not attempt to assess the consumer in the absence of the police.
7. Commissioner of Police should draw to the attention of all officers who have not had mental health training their powers under section 195 of the Mental Health Act 1996. As resources allow the Commissioner should ensure that all officers receive appropriate training relating to mental health and their responsibilities and powers under the Mental Health Act 1996.