Inquest into the Death of Samaan Salah Tilmiz ELSAMIN

21y · Male·unascertained

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.