Australia: A review of the Coroner's Inquest into the deaths of patients of the Alma Street Centre (Ref No: 15/15)

Last Updated: 8 June 2016
Article by Shannon Mony and Terri James

When Mental Health Services Are Broken
A review of the Coroner's Inquest into the deaths of patients of the Alma Street Centre (Ref No: 15/15)

Key Points

  • The Coroner's Court of Western Australia held a three week inquest to investigate a cluster of five patient deaths at the Alma Street Centre that occurred within a one year period.
  • Each death was the result of suicide, which the Coroner described as both predictable, and preventable.
  • The Coroner acknowledged that in all cases there was a breakdown of communication between the mental health service and the families and carers of the patient. At the material time the Mental Health Act 1996 (WA) offered little guidance for the requirements for carer involvement and access to information.
  • The Coroner criticised the clinical judgement of the treating clinicians, and acknowledged the inadequacies of the system. The Stokes Review has since addressed many of the issues, and many changes had already been implemented at the time of the inquest.


On 28 April 2015 an inquest was held at the into the deaths of five former patients of the Alma Street Centre, which is the psychiatric unit that makes up part of the mental health services offered at Fremantle Hospital. Each of the deaths were reportable deaths under section 3 of the Coroners Act 1996 (WA).

The cluster of patient deaths (between March 2011 and March 2012) was investigated during a three-week inquest after concerns were raised about the delivery of mental health services by the Alma Street Centre. Two patients died within 24 hours of discharge. One patient was an involuntary patient who absconded and died the same day. One patient disappeared within 24 hours of discharge and was discovered dead at later date. One patient died one month after discharge.

Four of the former patients had been at chronic risk for suicide for a number of years and had shown signs of being at acute risk of suicide in the period before their deaths.

As part of her investigation the Coroner considered the expert reports of Former Chief Psychiatrist Dr Davidson, and Chief Psychiatrist Dr Gibson. The Coroner also addressed observations from The Stokes Review 2012 that were relevant to the care of the deceased patients.

The Coroner considered that the primary matters of relevance, concerning the care of mental health patients, are in regard to whether suicide can be predicted or prevented. The experts opined that:

  • Suicide is preventable: It is not always possible to prevent suicides but the mental health clinician has a central role in suicide prevention including the importance of using a collaborative approach and community participation
  • Suicide is difficult to predict: clinical judgement and structured tools of assessment can assist with predicting suicide.
  • The treatment and care of each of the deceased is to be assessed by reference to the requirements of the Mental Health Act 1996 (WA) (the relevant legislation at the date of the deaths.)
  • The degree of reliance that clinicians should place upon the patient's assurances that they would not act upon suicidal thoughts is a vey finely balanced judgement.
  • There is no room for complacency in treating mental health patients.

The Issues at the Inquest

The inquest focused upon the actions taken by the clinicians in each of the five cases. This included a review of the clinical judgement of each clinician. The Coroner found that the words "clinical judgement" could not be used to stave off criticism and inquiry.

The Coroner considered the time pressures upon the clinician and their reduced capacity to engage with the carers. This was particularly relevant where the patient had been discharged.

Matters Common to these deaths

Communication and the Involvement of Carers

Communication was of a standard below what was expected of a professional mental health service.

At the material time the Mental Health Act 1996 (WA) protected the patient's confidentiality and no requirements existed for carer involvement, except in certain situations. It was also very busy at the material time and the psychiatrist's workload was very heavy.

The Coroner was satisfied that it wasn't a concern about patient confidentiality that stopped the clinicians involving the families. She also said that if such concerns did exist they were unfounded particularly when the decision involved the discharge of the patient. The coroner did acknowledge that there has been improved communication with carers since these cases were first investigated.

The Coroner believed that at the relevant time the Alma Street Centre did not have adequate policies in existence to support staff members in their contact with the carers, particularly in relation to admission or discharge of their family member.

Adequate Procedures for Considering Longitudinal Risks

The Coroner found that at the material time there was no adequate procedure for drawing together the relevant history of a patient, without a clinician having to revisit all of the medical records. The implications of this are that if a patient's primary clinician was not available, another clinician cannot immediately assess a patients material longitudinal risk factors and make an informed clinical judgement. This is particularly relevant in an environment that is time poor and highly stressed such as a crisis situation.

Recent changes have lead to the formation of an Assessment and Treatment Team (ATT) that is involved in assessment and long-term treatment of a patient, for continuity of care. This has made an improvement to the fragmented care previously offered.


  • Carer's Plans: The Coroner has identified that there needs to be a greater emphasis on providing information to the carers. The transition of patients into the community can only be successful where they have the support of family members and carers. Carer involvement in discharge planning would hep focus the clinician's mind. The plan should include information about the diagnosis and medication regimes, relapse prevention and include ways the carer can address their concerns about caring for the patient, addressing carer fatigue, respite and carers' allowances.
  • Resourcing for Mental Health system: Recommendation that the Western Australian government continues its efforts to address the delivery of mental health services and provides funding and resources required to progress the Stokes Review Recommendations and the Chief Psychiatrists standards from the planning stage to the implementation stages.

The Law

The two main issues identified and criticised by the Coroner involve the process of making a patient involuntary and also the involvement of carers in the provision of mental health services.

Since the deaths of the five mental health patients at Alma Street the Mental Health Act 1996 (WA) has been superseded by the Mental Health Act 2014 (WA) (which commenced on 30 November 2015). The same principle of the Mental Health Act remains: the best possible care and treatment be provided with the least restriction of patient's freedom.

The Mental Health Act 2014 (WA) treats patient confidentiality differently. There is still a statutory requirement regarding confidentially, however, statutory provisions also oblige the mental health services to involve carers and family members.

A carer is usually a family member or a person who is a carer under the Carers Recognition Act 2004 (WA).

The clinician is required to proactively engage carers, even in some situations where a patient declines the release of information. The clinician must clearly document their reasons for involving or not involving family and carers. This is crucial because section 319(2)(e) of the Mental Health Act 2014 (WA) states that a complaint may be made to the Health and Disability Complaint Service (HADSCO) on the basis that a service provider acted unreasonably in disclosing records or confidential information.


In mental health care there is no room for complacency. Suicide is the main cause of premature death in mental health patients. As the demand for services increases so must our capacity to deliver adequate mental health services.

The importance of community participation in the care of the state's mental health patients is essential. Involvement of the families and carers of the patients in discharge planning, and utilising community programs is paramount to decreasing the incidence of suicide.

The deaths of the five patients of the Alma Street Facility, and a prior coronial investigation into deaths at Greylands, has initiated much change into the provision of mental health services in Western Australia. Some of these changes were implemented prior to the Coroner's Inquest.

The Stokes Review, which was released in November 2012, found that mental health services were inadequate to meet the mental health needs of Western Australia. The Western Australian Mental Health, Alcohol and Drug Services Plan 2015- 2025 will continue to review and develop these services in Western Australia. The plan has already addressed many issues identified in the inquest of the five deaths at Alma Street Facility.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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Shannon Mony
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