Inquest into the Death of Peter Daniel Mahoney

Contributing factors

• Treatment-resistant bipolar affective disorder
• Medication non-compliance
• Inadequate supervision during approved leave
• Family members not fully informed of patient's involuntary status and potential for deception
• Hospital failed to fully inform police of patient's potential for harm to himself and family when he absconded
• Decision not to report sleeping pill poisoning incident to police, reducing police awareness of risk
• Opportunity to abscond while on leave
• Patient's insight into hopelessness of his future circumstances
• Delusions including belief he had AIDS

Coroner's recommendations

1. The full circumstances of an involuntary patient's potential for harm, as part of their illness, be made known to police when it is necessary to report an involuntary patient has absconded detention.
2. Support for new procedures put in place by Joondalup Health Campus for the release of involuntary patients for leave from their supervision into the supervision of someone else.
3. The fact of an involuntary patient's supervision being handed from one entity to another be formally recorded by way of reciprocal signatures at all hand overs.
4. Patients' illness that raises the possibility the patient may try to manipulate circumstances should be made verbally clear to those assuming responsibility for them during leave.