Inquest into the Death of Michael Ronald THOMAS

Unknown·Ruby: ligature compression of neck (hanging); Carly: ligature compression of neck (hanging); Michael: unknown/unascertainable; Anthony: multiple injuries; Stephen: multiple injuries

Five young adults died by suicide within 12 months (March 2011 to March 2012), all connected to Alma Street Centre mental health services at Fremantle Hospital. Four were discharged (Ruby Nicholls-Diver, Carly Elliott, Michael Thomas, Anthony Edwards) and one absconded while involuntary (Stephen Robson). Common failures included: inadequate individualised and risk management plans; poor integration of care; insufficient communication with families despite no confidentiality barriers; failure to contact next-of-kin before discharge; rushed clinical decision-making; inadequate follow-up post-discharge; lack of procedures for considering longitudinal risk factors; and insufficient policies guiding carer involvement. Key system issues were staff stress, resource constraints, and fragmented service delivery. The coroner found clinical judgements were amenable to review and several fell below acceptable standards, particularly discharge decisions made hastily without adequate assessment or family consultation.