Western Australia

Coronial Inquests published by the Australian, Western Australian Coroner.

Hayden Paul STACEY

Inquest into the death of Hayden Paul STACEY

Summary: Mr Stacey died on 27 May 2018 in a carpark located in Wananup from a gunshot wound to the chest. He was 22 years old.\r\n\r\nPrior to his death Mr Stacey was involved in an incident with police. He had armed himself with a large kitchen knife and refused to drop the weapon despite being repeatedly called on to do so. Police tried unsuccessfully to subdue Mr Stacey with their Tasers on three separate occasions. He then advanced on one of the police officers, still armed with a knife and was shot once in the chest. He died from his injuries.\r\n\r\nThe Coroner accepted police had tried to engage with Mr Stacey, and because of his agitated and evasive behaviour they considered he was having some form of mental health episode. Police intended to take Mr Stacey into custody for assessment. The Coroner found police officers were unable to de-escalate the situation which they were confronted with and so took non-lethal force option by deploying their Tasers. The Coroner accepted police officers believed Mr Stacey posed a serious and imminent threat, not only to their own lives, but also to the lives of others.\r\n\r\nThe Coroner was satisfied that the police officers conducted themselves reasonably when they interacted with Mr Stacey and that the police officer who fatally shot Mr Stacey had acted lawfully and reasonably.\r\n\r\nThe Coroner made one recommendation relating to a proposed new Taser system.\r\n\r\nCatch Words: Body worn cameras for police : Taser deployment : Gunshot Injury : Homicide by way of self-defence.

Coroner Jenkin on 18 August 2020


Jessica Lesley JACKSON

Inquest into the death of Jessica Lesley JACKSON

Summary : Ms Jackson was training for an amateur Muay Thai contest in late 2017. In order to meet her chosen weight category for the fight she had to lose a significant amount of weight in a two month period. She embarked on an intensive diet and training regime. In the last week she embarked on a weight cutting program, which involved drinking excess water, slowly taping off to no water at all. She was 18 years old.\r\n\r\nOn the morning of the weigh-in Ms Jackson still had 2 kgs to lose to reach the required weight before the weigh-in that afternoon. As part of her plan to lose the weight, she did not drink any water and tried to sweat out water in her body through taking hot baths and going to a sauna in the morning. She then went to the gym and trained hard.\r\n\r\nWhen Ms Jackson was observed at the gym around 2.30 pm she appeared dehydrated, tired, fatigued and had sunken eyes. She was doing a lot of running and jogging but she felt she was not sweating enough, so put on a sweat suit on and off as she continued to train. She was focused on achieving her weight loss. Ms Jackson was asked if she could keep going and she responded that she wanted to keep going and she felt she could do it. Ms Jackson went outside the gym wearing a sweat suit and beanie and commenced running up and down the road at the back of the gym. She was then observed to stagger sideways before she fell over on her side and collapsed. She was unresponsive, her eyes were unfocussed and she had shallow breathing. It was clear Ms Jackson was critically unwell and an ambulance was called and she was taken to Fiona Stanley Hospital as a Priority 1 emergency. At Fiona Stanley Hospital Ms Jackson was admitted from the Emergency Department to the Intensive Care Unit, where her condition deteriorated with worsening multi-organ failure. She died on 14 November 2017 as a result of multi-organ failure due to the combined effects of environmental exposure (hyperthermia) and dehydration. The Coroner found the death occurred by way of misadventure.\r\n\r\nThe Coroner made two recommendations aiming to better regulate trainers and gyms to improve the safety of combat sports in Western Australia.\r\n\r\nCatch Words : Combat Sport : Dangers of Weight Cutting : Misadventure

Coroner Linton on 18 August 2020


Susan Jessica Elsie WINDIE

Inquest into the Death of Susan Jessica Elsie WINDIE

Summary : Ms Windie died on 29 October 2016 from complication of a rare, life-long condition. She was 22 years old.\r\n\r\nMs Windie was born with genetic abnormalities which predisposed her to recurrent constipation, for which she was treated at Carnarvon Hospital and at tertiary hospitals in the Perth metropolitan area. On 27 October 2016, she was admitted to the Carnarvon Hospital with severe constipation. Doctors contacted Sir Charles Gairdner Hospital to seek advice and to arrange for Ms Windie to be transferred there, but she was kept at Carnarvon Hospital for further management.\r\n\r\nOn the evening of 28 October 2016, Ms Windie experienced increasing pain and then developed abdominal compartment syndrome from what was later determined to be pseudo-obstruction from faecal impaction. Arrangements were made for her to be transferred to Perth, but by the time the Royal Flying Doctor Service team arrived, her condition was incompatible with survival.\r\n\r\nThe Coroner concluded that Ms Windie died from a condition that was readily treatable had she been transferred to a tertiary hospital in time. The Coroner did not find that any of the doctors involved with her care acted unreasonably in the circumstances. The Coroner found that, since Ms Windie’s death, there have been improvements to the process of accepting transfers of patients into tertiary hospitals from rural hospitals, and there was a proposed acute patient transport coordination service.\r\n\r\nCatch Words : Genetic Abnormality : Pseudo-obstruction : Faecal Impaction : Abdominal Compartment Syndrome : Rural Patient Transfer : Natural Causes

Deputy State Coroner King on 13 August 2020


Amy-Lee ARMSTRONG and Kyrone Terrance EADES and Ashley Scott De AGRELA

Inquest into the Deaths of Amy-Lee ARMSTRONG and Kyrone Terrance EADES and Ashley Scott De AGRELA

Summary : On 2 December 2015, Ms Armstrong, Mr Eades and Mr De Agrela were passengers in a car which was being driven at high speeds. The driver, who was affected by methylamphetamine and alcohol, lost control of the car and crashed into a tree in South Lakes. Ms Armstrong and Mr Eades died from their injuries at the scene of the crash, and Mr De Agrela died from his injuries two days later in hospital. The driver of the car survived.\r\n\r\nPrior to the crash, police officers had pursued the car briefly but then lost sight of it.\r\n\r\nThe driver was convicted of three counts of dangerous driving occasioning the deaths of each of Ms Armstrong, Mr Eades and Mr De Agrela in circumstances of aggravation and with failing to comply with a direction by the police officers to stop.\r\n\r\nThe Deputy State Coroner found that each of the deaths occurred by way of unlawful homicide.\r\n\r\nThe Deputy State Coroner concluded that the officers acted appropriately and did not cause or contribute to the crash.\r\n\r\nCatch Words : Police Intercept : WA Police Emergency Driving Policy and Guidelines : Alcohol : Methylamphetamine : Tetrahydrocannabinol : Excessive Speed : Failure to Stop : Unlawful Homicide

Deputy State Coroner King on 7 August 2020


Stephen Michael KELL

Inquest into the death of Stephen Michael KELL

Summary: Mr Kell was a 35 year old man who died at Graylands Hospital on 25 April 2015 from complications of an acute large intestine obstruction. At the time of his death Mr Kell was subject to an Involuntary Patient Order made under the Mental Health Act 1996.\r\n\r\nMr Kell was diagnosed in 2001 as suffering from chronic paranoid schizophrenia and it was reported he displayed symptoms of his illness since he was 18 years old. He responded poorly to clinical treatments and his condition was exacerbated by his ongoing abuse of illicit substances.\r\n\r\nMr Kell was prescribed antipsychotic medication, clozapine to treat his mental illness, because his condition was non-responsive to other anti-psychotics. Upon his June 2012 admission to Graylands Hospital it was noted that his clozapine had been ceased due to a low white blood cell count. However, his mental health deteriorated from the time of cessation.\r\n\r\nFollowing consultations with him and his family, and compliance with the manufacturer’s processes, Mr Kell was recommenced on clozapine in May 2013, with medication to boost his white blood cell count. . In March 2015 his involuntary patient status was reviewed and extended for a further three months.\r\n\r\nIn the months leading up to his death Mr Kell’s behaviour and mental state were noted to fluctuate. He appeared to be responding to unseen stimuli, and on occasion displayed difficult behaviours. Mr Kell was granted day leave on 24 April 2015 and upon his return it was thought, but not confirmed, that he may have used drugs. On the evening of 25 April 2015 when approached for his medications he was unable to communicate, he had a tremor and an elevated heart rate. His tremor and heart rate subsequently settled, but later that night his condition rapidly deteriorated. He became unresponsive and despite resuscitation attempts he remained in asystole and died in the early hours of 26 April 2015. Clinicians did not know why Mr Kell had died.\r\n\r\nAt the inquest the State Coroner heard expert evidence about clozapine-induced gastrointestinal hypomotility, and found that Mr Kell developed this condition by reason of his treatment with clozapine, that contributed to his death. Unfortunately this potentially fatal condition was not well known known at the time, and Mr Kell did not display symptoms consistent with intestine obstruction or motility issues.\r\n\r\nThe State Coroner made one recommendation to the Department of Health to consider updating Guides and Polices relating to the safe and quality use of clozapine in the WA Health System, to warn of the potentially fatal risk of clozapine-induced gastrointestinal hypomotility. The other recommendation was made to the distributors of clozapine, Pfizer and Mylan, and included updating their Product Information to highlight the risk of clozapine-induced gastrointestinal hypomotility with a prominent “boxed warning”..\r\n\r\nThe State Coroner was satisfied that Mr Kell’s supervision, treatment and care was appropriate to his needs. The State Coroner found Mr Kell’s death arose by way of misadventure.\r\n\r\nCatch Words: Clozapine induced gastrointestinal hypomotility :: Updating clozapine Prescribing Policy : Updating clozapine Prescribing Information : Misadventure

Coroner Fogliani on 6 August 2020


Shirley June FINN

Inquest into the death of Shirley June FINN

Summary: On the morning of 23 June 1975, the body of brothel-keeper Shirley June Finn was found in the driver’s seat of her car, parked beside the Royal Perth Golf Club on the verge of Melville Parade in South Perth. She had four gunshot wounds to the head. She was 34 years old.\r\n\r\nThe Deputy State Coroner found that death occurred by way of unlawful homicide. He was unable to determine the person or persons responsible.\r\n\r\nCatch Words: Corruption : Prostitution : Long Term Investigation : Murder Suspects : Unlawful Homicide

Deputy State Coroner King on 4 August 2020


Desmond Richard KICKETT

Inquest into the death of Desmond Richard KICKETT

Summary : Immediately before his death, Mr Kickett was involved in a violent incident at his former partner’s house which police attended. Mr Kickett died at Royal Perth Hospital on 29 June 2018, from multiple organ failure following cardiorespiratory arrest in a man with focal coronary arteriosclerosis and amphetamine effect. He was 34 years of age.\r\n\r\nOn the evening of 28 June 2018 Mr Kickett’s ex-partner was at home with three of her children when Mr Kickett arrived unexpectedly and knocked at the front door. There had been a history of family domestic violence by Mr Kickett and some more recent threats, and for that reason, his ex-partner did not allow him inside the house. Mr Kickett told his ex-partner he had come to collect a car he had loaned her, but she told him to come back the next day as the car was not there.\r\n\r\nMr Kickett then asked for a smoking implement which his ex-partner understood to mean he wanted something he could use to smoke methylamphetamine with. She gave him a light glbe to get rid of him and Mr Kickett left the premises. Mr Kickett’s ex-partner helped the children to bed and retired herself at about 2.00 am on 29 June 2018. Sometime later, the family were woken by a loud bang as Mr Kickett smashed his way through a glass sliding door at the rear of the house and came inside. He then tried to force his way into the main bedroom where his ex-partner and two of children were hiding. She begged him to stop what he was doing and he eventually did so and lay on the floor in the hallway outside the main bedroom door. Mr Kickett was naked and moving about on the floor. Mr Kickett’s ex-partner’s daughter and a neighbour called emergency services and asked for urgent police attendance.\r\n\r\nPolice arrived at the premises at about 6.21 am on 29 June 2018. They spoke with Mr Kickett’s ex-partner through her bedroom window and after jumping the side fence, entered the home through the smashed rear door. Police found Mr Kickett lying on his back in the shower recess in the bathroom, covered in what appeared to be liquid soap. He was rambling incoherently and moving about in an erratic manner. Police considered that Mr Kickett was under the influence of illicit drugs and needed to be taken into custody for a mental health assessment.\r\n\r\nPolice placed handcuffs on Mr Kickett, with his hands in front of his body and removed him from the house and secured him in the passenger pod of their police vehicle. Police called an ambulance, which was dispatched on a priority 2 basis. While police waited for the ambulance to arrive, they conducted enquiries and Mr Kickett was checked every minute or so. Shortly before 6.40 am, police noted that Mr Kickett’s breathing appeared to be shallower and he was removed from the passenger pod for assessment. Mr Kickett suddenly became unresponsive and police started CPR and asked for the urgent attendance of an ambulance. An ambulance arrived at the scene at 6.47 am and as he was being taken to Royal Perth Hospital, officers achieved a spontaneous return of circulation. As Mr Kickett was about to be admitted to the intensive care unit, he became difficult to ventilate and he could not be revived.\r\n\r\nThe Coroner made two recommendations in respect to the passenger pods attached to police vehicles.\r\n\r\nThe Coroner found that attending police did not contributed to Mr Kickett’s death and highlighted the dangers of using methylamphetamine, especially in cases like Mr Kickett’s, where the user has pre-existing heart disease.\r\n\r\nCatch Words : Underlying Heart Condition : Use of Methylamphetamine : : CCTV footage in Passenger Pods of Police Vehicles : Excited Delirium : Accident

Coroner Jenkin on 31 July 2020



Inquest into the Death of RM CHILD

Summary: Child RM died on 16 April 2017 from ligature compression of the neck (hanging), she was 17-years of age. At the time of her death, she was in the care of the Chief Executive Officer (CEO) of the Department of Communities (the Department).\r\n\r\nChild RM first came to the attention of the Department of Communities in 2000 when she was 12-months old. In 2001, following an assessment by the Department, she was placed into foster care for 2 weeks before being returned to the care of her parents. In 2007 the Department was concerned about the inability of either of Child RM’s parents to provide her with a safe environment and she was removed from their care on 8 September 2008. Child RM came into the care of the CEO on 4 March 2009, when a Protection Order (until age 18 years) was made in the Children’s Court of Western Australia.\r\n\r\nBetween 2008 and 2011, Child RM was the subject of numerous out-of-home placements organised by the Department, including general carers, family carers and residential homes. These placements invariably broke down mainly because of Child RM’s increasingly challenging behaviours. When her placements broke down, Child RM tended to “self-select” placements with either her mother or her father, neither of which were approved carers by the Department. Between late 2011 and early 2012, the Department investigated concerns regarding Child RM being exposed to harm including historical sexual abuse, emotional harm and physical harm.\r\n\r\nBetween 2012 and January 2017, Child RM was admitted to the Kath French Secure Care Centre (the Centre) on four occasions. Children may be placed in “secure care” for periods of up to 42-days (up to 21-days initial placement and up to a further 21 days in exceptional circumstances), but only when they are at imminent risk to themselves and others and only then, where there are no other available options. The Centre provides a therapeutic time limited “circuit breaker” designed to stabilise the child’s behaviours.\r\n\r\nWhile in secure care, Child RM was not drinking alcohol and she attended medical appointments and education sessions about self-care and safety. After leaving secure care for the last time, Child RM was referred to Indigo Junction in Midland, an agency that offers services to young people at significant risk of homelessness. After a few days at the service, Child RM left to live with her father on 24 February 2017.\r\n\r\nDuring the evening on 15 April 2017, Child RM was with her boyfriend and her mother and a number of other people near the large screen adjacent to the State Library in Northbridge. Child RM and her boyfriend had been arguing and she had been drinking with some other girls. After Child RM’s boyfriend was arrested for disorderly conduct and then released, he and Child RM caught the bus in the direction of Child RM’s father’s home. At about 10.30 pm, Child RM and her boyfriend were observed fighting on the bus. The driver stopped and called Transperth security. As he got off the bus after it had stopped, Child RM’s boyfriend spat at the bus driver.\r\n\r\nPolice attended and arrested Child RM’s boyfriend. They repeatedly offered Child RM a lift to her father’s home but she declined. She said she had lived on the streets before and preferred to walk there. Although she had initially been agitated when her boyfriend was arrested, when police left Child RM at about 11.15 pm on 15 April 217, she appeared to be calm and seemed happy. Police had no concerns for her welfare.\r\n\r\nChild RM was found by two members of the public at about 11.35 pm, hanging from a verge tree in Morley, with a garden hose around her neck. Emergency services were called and Child RM was taken to Sir Charles Gairdner Hospital, where despite the efforts of members of the public, the police and hospital staff, she could not be revived.\r\n\r\nThe Coroner found Child RM’s parents were not able to provide Child RM with a safe environment despite the fact that Child RM clearly wanted to spend time with them. The Coroner was satisfied that the Department of Communities did what it could to address Child RM’s complex needs but found that there missed opportunities where additional support from the Department may have altered Child RM’s life. The Coroner made three recommendations relating to the services provided to traumatised children who entre secure care.\r\n\r\nCatch Words: Children in Care : Complex community care service : Cultural Therapeutic Specialist : Suicide

Coroner Jenkin on 16 July 2020


SJC Child

Inquest into the Death of SJC Child

Summary : Child SJC died on 20 November 2017, from complications relating to metastatic neuroblastoma, an aggressive form of cancer that predominantly affects young children. At the time of her death, Child SJC was in the care of the Department of Communities (the Department).\r\n\r\nChild SJC was born on 26 June 2015. Concerns were raised about the ability of her mother to care for her and Child SJC was placed on a 12-month supervision order by the Department. The order was subject to monitoring conditions and Child SJC’s mother appeared to be coping well and received positive reports about her parenting.\r\n\r\nFollowing a review for a bruised eye, Child SJC was diagnosed with Stage IV high-risk neuroblastoma on 23 May 2016 during her admission to Princess Margaret Hospital (PMH). The primary tumour was identified in her right adrenal gland and secondary tumours were found in her liver, skull and the bones of her arms and legs. PMH staff encountered difficulties contacting Child SJC’s mother to obtain consent for various medical procedures and on 15 June 2016, Child SJC was taken into the care of the Department for a period of two years and placed in the care of her maternal great-grandmother.\r\n\r\nChild SJC underwent an intensive treatment regime that included surgery, chemotherapy, radiotherapy and immunotherapy, and initially she responded well. She was discharged home on 10 January 2017, apparently in remission. However, Child SJC relapsed on 7 August 2017 and a right sided pelvic mass was detected along with tumours to the right groin, the lymph system at the back of her right knee and her skeletal bones and bone marrow.\r\n\r\nThe standard immunotherapy treatment regime for children with Stage IV high-risk neuroblastoma was treatment with Dinutuximab, which was made available free of charge to PMH by a company in the United States of America as part of a world-wide clinical trial. However positive clinical trials caused a surge in demand for the substance, and in late November 2016, the American company announced that it would no longer be made available to patients outside the US. In collaboration with other children’s hospitals around Australia, PMH sourced supplies of an alternative known as Dinutuximab Beta. PMH then obtained approval to purchase this substance until Dinutuximab became available again.\r\n\r\nAlthough Child SJC’s treatment with chemotherapy and Dinutuximab Beta began on 10 August 2017, her tumours continued to grow and the treatment was ultimately unsuccessful. Indeed, scans on 6 October 2017, showed there had been no response to this treatment and Child SJC’s tumours continued to progress. Child SJC underwent palliative radiotherapy, primary to control pain.\r\n\r\nOn 7 November 2017, a new mass was noted Child SJC’s jaw and her condition began to deteriorate. Further tumour deposits were found in her jaw and knee when she was reviewed on 15 November 2017 and on 17 November 2017, it was felt her death was imminent. Child SJC was surrounded by her family when she died on 20 November 2017.\r\n\r\nThe Coroner was satisfied the care, supervision and treatment provided to Child SJC by the Department was of an acceptable standard. The Coroner made one recommendation relating to the supply of Dinutuximab.\r\n\r\nCatch Words : Neuroblastoma : : Availability of Dinutuximab : Child in Care : Comment on Care, Treatment and Supervision : natural causes

Coroner Jenkin on 1 July 2020


Thorvald Anthony NIELSEN

Inquest into the death of Thorvald Anthony NIELSEN

Summary: Mr Nielsen died on 13 April 2017 in a carpark adjacent to the Darlington Tennis Club, from multiple gunshot wounds. Mr Nielsen, who was then 29 years of age, was shot by officers from the Western Australian Police Force’s Tactical Response Group (TRG) in circumstances where he was armed with a shotgun and the officers reasonably believed that their lives (and the lives of others) were at imminent risk.\r\n\r\nSometime between late December 2016 and early January 2017, a shotgun and a rifle (the firearms) were stolen from a rural property near York. Police suspected that Mr Nielsen was responsible for the theft of the firearms and as it transpired, when he was shot by TRG officers, Mr Nielsen was found to in possession of the stolen shotgun. In April 2017, police suspected that Mr Nielsen was involved in three separate “fail to stop” incidents. In relation to the third incident, police eventually located the abandoned car they had been chasing and found a wallet containing cards in Mr Nielsen’s name.\r\n\r\nAt the time of his death, Mr Nielsen was living with his partner in Northam. She was unaware of any criminal activity on his part and he was very secretive about his movements. Mr Nielsen was the subject of a suspended imprisonment order, and he developed an irrational belief that if police arrested him, he face a lengthy jail term. He had also told his partner and others that he would not willingly surrender to police and instead, would take his own life. Police were aware of Mr Nielsen’s threats and his deteriorating mental state and they strongly suspected that he may be in possession of the firearms. For that reason, police regarded Mr Nielsen as a serious threat to himself and the public and they were “strongly motivated” to apprehend him.\r\n\r\nOn 13 April 2017, Mr Nielsen arranged to meet his partner at the Darlington tennis courts at about 5.30 pm. His partner had told police about the meeting and was aware that Mr Nielsen was to be apprehended, but she was told that this was so that he could receive a mental health assessment. Mr Nielsen’s partner was not told that police strongly suspected that Mr Nielsen was in possessions of the firearms and she subsequently said that if she had been made aware of this, she would not have assisted police by arranging the meeting with Mr Nielsen.\r\n\r\nMr Nielsen arrived at the tennis courts in a car driven by an acquaintance. His partner was already there and he got out of his car and spoke with her briefly. However, when she said: “It’s not safe here”, Mr Nielsen headed back to his car. As he did so, TRG officers in several cars moved in and ordered Mr Nielsen to stop. He ignored these orders and instead, got back into his car and closed the door. He then unwrapped a shotgun located in the front passenger footwell and pointed it at his chin. By this time, TRG had surrounded Mr Nielsen’s car and they repeatedly ordered him to put the shotgun down and get out of the car.\r\n\r\nA TRG officer opened the front passenger door and again, officers repeatedly ordered Mr Nielsen to drop his weapon. Mr Nielsen did not respond and a TRG officer fired a TASER at him through the open driver’s side passenger door. Although one of the TASER probes hit Mr Nielsen’s cheek, the other missed and the TASER was therefore ineffective.\r\n\r\nMr Nielsen continued to ignore the orders of the TRG officers to drop his weapon and instead, he pointed the shotgun at officers on either side of the car. By this time, Mr Nielsen’s partner was standing close to TRG officers on the passenger side of the car and was also yelling at Mr Nielsen to put the shotgun down. In fear of their lives and the lives of others, four TRG officers fired a total of five shots into Mr Nielsen’s body. The five shots were fired within a matter of a few seconds and caused Mr Nielsen to slump forward in his seat.\r\n\r\nA police officer who was observing events ran forward and managed to move Mr Nielsen’s partner to safety, but not before all five shots had been fired. The TRG officers removed Mr Nielsen from the car and gave him first aid. Contrary to established practice, none of the TRG vehicles at the scene were carrying first aid kits and officers were obliged to use their own personal kits. The shotgun was removed from the care and found to be loaded. An ambulance took Mr Nielsen to hospital, where he was declared deceased.\r\n\r\nCatch Words: TRG Operations : Use of Force by Police : Snatch Arrest: Appropriate Risk Assessments : Multiple Gunshot Wounds : Homicide by way of Self-defence.

Coroner Jenkin on 15 June 2020