Inquest into the Death of Stone

AI-generated summary

Pamela Stone, a 62-year-old woman with a complex history of trauma, depression and relationship difficulties, presented to Albany Regional Hospital ED on 26 March 2009 after a violent altercation at home, having been sedated by paramedics. She was placed on a Form 1 mental health assessment order by Dr L.. However, the G Ward psychiatric unit had no bed capacity, and both available consultant psychiatrists declined to assess her—one citing lack of bed space, the other citing policy that she must be admitted to G Ward first. Dr L. reassessed her at 2pm, found her calmer and without expressed suicidal intent, and rescinded the Form 1 and discharged her. The coroner found his reassessment decision reasonable given the circumstances, but criticised the system failure: no psychiatrist assessed her despite two being on-site, and the policy blending 'receipt' and 'admission' to G Ward effectively prevented psychiatric assessment. She was discharged without proper discharge planning. Within hours, after a violent altercation at home, she drove to Torndirrup National Park and died by suicide. The coroner found systemic failures in ARH's application of the Mental Health Act 1996, particularly the refusal of psychiatrists to assess her due to bed-space policy, and lack of ED support protocols and liaison services for patients under psychiatric orders.

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