RECORD of INVESTIGATION INTO DEATH Ref: 51/12
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Coroners Act 1996 [Section 26(1)] Western Australia RECORD OF INVESTIGATION INTO DEATH Ref: 51/12 I, Barry Paul King, Coroner, having investigated the death of Kevin Maxwell Collins with an inquest held at the Perth Coroner’s Court, Court 51, CLC Building, 501 Hay Street, Perth, on 25 February 2014, find that the identity of the deceased person was Kevin Maxwell Collins and that death occurred on 31 August 2010 at Graylands Hospital from bronchitis (pandemic influenza A/H1N1 2009) in a man with chronic obstructive pulmonary disease in the following circumstances: Counsel Appearing: Ms M. Smith assisting the Coroner Ms R Hartley (State Solicitors Office) appeared for Health Department WA, Graylands Hospital, Francis Kuranja, Patrick Devellerez, Dr Korede Ayeni and Dr Babu Mathew Ms B Burke (ANF) appearing on behalf of John Holmes Table of Contents Introduction ...................................................................................... 1 The Deceased .................................................................................... 4 1986 to 2009 ..................................................................................... 5 2010 ................................................................................................. 7 Events Leading Up To Death ............................................................ 10 Cause Of Death ............................................................................... 13 How Death Occurred ....................................................................... 14 Quality Of The Supervision, Treatment And Care Of The Deceased .. 14 INTRODUCTION Inquest into the death of Kevin Maxwell Collins 1 1. Kevin Maxwell Collins (the deceased) died on 31 August 2010 at Graylands Hospital (Graylands) at the age of 50 from bronchitis as a feature of pandemic influenza A/H1N1 2009 (swine flu) in the context of chronic obstructive pulmonary disease.1 2. As the deceased was an involuntary patient under the Mental Health Act 1996 at the time of his death, he was a ‘person held in care’ under section 3 of the Coroners Act 1996. 3. Section 22 (1)(a) of the Coroners Act 1996 provides that a coroner who has jurisdiction to investigate a death must hold an inquest if the death appears to be a Western Australian death and the deceased was immediately before death a person held in care. 4. An inquest to inquire into the death of the deceased was therefore mandatory. 5. Under s.25 (3) of the Coroners Act 1996, where a death investigated by a coroner is of a person held in care, the coroner must comment on the quality of the supervision, treatment and care of the person while in that care. 6. The death of the deceased was investigated together with the deaths of nine other persons who had been persons held in care as involuntary patients at Graylands under the Mental Health Act 1996 immediately before they died. 7. A joint inquest commenced before Coroner D.H. Mulligan in the Perth Coroner’s Court on 27 August 2012. Evidence was provided relating to the deaths of two of the other nine deceased persons. The inquest was then adjourned until it recommenced on 11 March 2013 when evidence relevant to another deceased person was adduced. 1 Ex 1 Vol 1 Tab 5 Inquest into the death of Kevin Maxwell Collins 2 8. On 18 and 19 March 2013 and 16 April 2013 evidence specific to the deceased was adduced. 9. On subsequent hearing days, evidence relevant to the other deceased persons and general evidence about Graylands was provided to the Court. The hearings were completed on 22 April 2013. 10. Coroner Mulligan became unable to make findings under s.25 of the Coroners Act 1996 so I was directed by Acting State Coroner Evelyn Vicker to investigate the deaths. 11. To remove any doubt of my power to make findings under s.25, on 25 February 2014 I held another inquest into the death of the deceased and the other persons. The evidence adduced in that inquest was that which had been obtained by Coroner Mulligan, including exhibits, materials and transcripts of audio recordings of the inquests. Interested parties who were present at the inquests before Coroner Mulligan were invited to make fresh or further submissions. All of the parties indicated their agreement with the appropriateness of the procedure I had adopted. 12. I should note that there was a great deal of evidence adduced at the inquest that was related to general or systemic issues pertinent to Graylands. That evidence was adduced to investigate whether those issues had a bearing on any or some of the deaths and to allow the coroner to comment on the quality of supervision, treatment and care of the deceased patients. For example, evidence of the condition of the buildings at Graylands containing wards was provided in order to allow the Court to investigate whether the physical environment of the wards would have been more therapeutic had the buildings been refurbished. 13. That general evidence was useful in providing an overview of the context in which the deceased persons were treated for their mental illnesses; however, in my view many of the issues the subject of that evidence Inquest into the death of Kevin Maxwell Collins 3 were not sufficiently connected with all the respective deaths for me to comment on those issues under s.25 (2) or (3) of the Coroners Act 1996 generally as if they did. 14. I have therefore not addressed those general issues separately from a consideration of each death. Rather, where I have come to the view that the issues were connected with the death or were potentially relevant to the quality of the supervision, treatment and care of the deceased, I have addressed them in the respective findings. THE DECEASED 15. The deceased was born in Swan District Hospital on 3 September 1959 as the second of seven children. His father was in the rail industry and the family moved around a lot when he was young. The deceased remembered his childhood as a happy time. 16. The deceased left school when he was 14. As a young man the deceased had steady jobs, usually as a labourer, and he travelled frequently. He had worked in an abattoir and as a storeman and a cheese maker prior to being stricken with mental illness. 17. He was a gentle person who was very social and had long-term friends, though he apparently told admitting doctors at Graylands that he lost all his friends when he became an evangelist Christian in 1987.2 18. When he was 27 or 28 the deceased started studying nursing at Curtin University. He lived in a caravan close to the university and began to use drugs, mainly cannabis. He would spend his income on drugs instead of food. 19. His elder sister went to visit him and saw that he was obviously ill so she and her husband took him to their 2 Ex 1, Vol 3, Tab 1 p137 Inquest into the death of Kevin Maxwell Collins 4 home to live with them. While there, the deceased suffered a schizophrenic episode so his sister took him to Fremantle Hospital where he was admitted. He was then transferred to Graylands where, on 3 November 1986, he was admitted for the first time.3 20. It appears that it was at this time that the deceased had the first schizophrenic episode of which his family was aware, though it appears that he suffered an earlier psychiatric episode in 1985 when he was admitted to Royal Perth Hospital.4 1986 T0 2009 21. During the deceased’s first admission to Graylands in 1986, he was diagnosed with schizophrenia. In the following years he was admitted another 16 times and spent almost all of 2008 and 2009 in Graylands. His last admission began on 24 March 2010.5 By then the deceased had been diagnosed with paranoid schizophrenia by at least two psychiatrists.6 22. On the occasions when the deceased was admitted to Graylands he generally presented with psychotic and affective (manic) symptoms. The psychotic symptoms included delusions, hallucinations and thought disorder. The manic symptoms included irritability, lability of mood, disinhibition and grandiosity. 23. Over the years the deceased had been treated with a variety of medications, both for his psychiatric symptoms and for his mood symptoms. In the early years of his treatment, his symptoms responded well to the medications, but as time went by, the medications had less effect, so that he was left with residual symptoms even after long admissions.7 3 Ex1, Vol 1, Tab 8 and Tab 11 4 Ex1, Vol 1, Tab 11 5 Ex 1, Vol 3, Tab 2 p1 6 Ex 1, Vol 1, Tab 11 p2 7 ts 96 Inquest into the death of Kevin Maxwell Collins 5 24. In 1988 the deceased overdosed on medications when he was at home. He was found in the back yard of his home and was taken to Royal Perth Hospital where he was admitted to the intensive care ward to be treated for aspiration pneumonia. 25. In April 2004 the deceased intentionally overdosed on medication and was found in a railway station toilet and taken to Sir Charles Gairdner Hospital emergency department.8 There is no other record of a suicide attempt by the deceased apart from this occasion and the previous one in 1988. 26. When not in Graylands, the deceased lived in various hostels as well as in caravan parks and sometimes on the street as a homeless person.9 It seems that over time the deceased had become institutionalised, in the sense that he was unable to cope outside of the environment with which he was familiar at Graylands.10 For example, there was evidence to suggest that, when he was discharged to a hostel, the deceased would refuse to go to the hostel and would present himself at Graylands instead. This may have been partly because living at a hostel would have been expensive for the deceased, and there would not be much money left over from his pension for cigarettes.11 27.