CITATION:	Inquest into the death of Dean Jigili [2016] NTLC 018

TITLE OF COURT:		Coroners Court

JURISDICTION:		Darwin

FILE NO(s):		D0006/2015

DELIVERED ON:		11 July 2016 

DELIVERED AT:		Darwin

HEARING DATE(s):		6 & 7 June 2016

FINDING OF:		Judge Greg Cavanagh

CATCHWORDS: 	Person in Care, psychosis, involuntary admission, absconded from Cowdy Ward, hanging, response from Top End Mental Health

REPRESENTATION:

Counsel Assisting:    		Kelvin Currie
Counsel for Department of Health: 		Greg Macdonald	
Counsel for Family:		Jessica Trappel

	

Judgment category classification:	A
Judgement ID number:	[2016] NTLC 018
Number of paragraphs:	49
Number of pages:	10

IN THE CORONERS COURT
AT DARWIN IN THE NORTHERN 
TERRITORY OF AUSTRALIA

No. D0006/2015
	In the matter of an Inquest into the death of 
	DEAN JIGILI
	ON 14 JANUARY 2015
AT BAGOT COMMUNITY, DARWIN

	FINDINGS

Judge Greg Cavanagh 
Introduction
1.	Dean Jigili (the deceased) and hereinafter referred to as Kwementyaye (at the request of his family) was a 23 year old indigenous man, born 20 November 1991 at the Katherine Hospital in the Northern Territory to Maria Jigili and Earl Gibson.
2.	Kwementyaye was raised in Lajamanu and was a talented AFL player. He was a respected young man and until the last few months of his life was never in trouble with Police.
3.	On 11 January 2015 he went to the red house in Lajamanu to have a shower and while there saw someone in the mirror that told him to hit his wife.  She tried to run away but fell and he assaulted her. He was sectioned under the Mental Health and Related Services Act and evacuated to Darwin the following day.
4.	He was admitted to the Joan Ridley Unit, a secure mental health facility on the campus of the Royal Darwin Hospital. He seemed to settle on medication and the following day he was transferred to the Cowdy Ward (a less secure Mental Health ward) at 11.00 am 13 January 2015.
5.	Sometime just before 6.00 pm he scaled the four metre fence around the open air court yard and made his way to the Bagot Community. There, he spoke to his grandmother who told him to sit down and watch a movie. She went to another house for a few minutes and on her return he had gone.
6.	The following morning he was found sitting under a tree some distance to the rear of his grandmother’s house. His legs were crossed and his hands folded in his lap. Around his neck was an electrical cord, the other end of which was tied to a rope hanging from a branch of the tree. He was dead.
Psychosis

7.	His death was a surprise to his family and his treating medical specialists. Until four months previously there was no suggestion that he had any serious problems.
8.	In 2009 he had met his partner Kaitlyn Cox in Lajamanu. She was from Ringers Soak, a small Community in Western Australia. They lived together in both Lajamanu and Ringers Soak.
9.	They had a child in 2013, Matthew Jigili. However he passed away shortly after birth.
10.	In his late teens and early twenties Kwementyaye began travelling to Katherine with family and friends and while there would drink alcohol. However that didn’t seem to affect his behaviour when back at Lajamanu. He returned as the same respectful young man.
11.	In September 2014 Kwementyaye and Kaitlyn were living in Ringers Soak. They had been living there for about a year.  Kwementyaye travelled back to Lajamanu for royalty meetings and Kaitlyn stayed in Western Australia. 
12.	While there he went to Katherine for a football match. On the journey back his family thought he started going ‘mad’. He appeared to be hallucinating. From that point he had problems sleeping at night. His uncle sat up with him one night until daylight because Kwementyaye was hearing voices. He said he could see people others couldn’t and he wanted to run off to be with them.
13.	His family thought that while in Katherine he had bumped into a stranger and had witchcraft put on him. Kwementyaye told the psychiatrist that he had smoked two cones of Cannabis and the next day the voices started.
14.	At the hearing of this inquest I heard evidence that it is likely that cannabis use lead to the psychosis experienced as well as a more prolonged illness characteristic of schizophrenia. Professor Parker explained that it is likely that Kwementyaye fell into the percentage of the population that has genetic difficulty in metabolising brain dopamine. 
First Admission

15.	On 2 November 2014 a member of the night patrol in Lajamanu reported Kwementyaye’s abnormal behaviour to the Health Clinic. The behaviour had been ongoing at that stage for about seven days. Kwementyaye was visited at his home by the Clinic nurse. He said he was hearing voices and that the voices were angry. 
16.	He agreed to go to the Clinic. The Clinic notes state: “Pt asked directly if he has thoughts about harming himself – he appears to indicate yes, the voices tell him to harm himself”.
17.	The District Medical Officer (DMO) was called and a Careflight evacuation to Royal Darwin Hospital arranged.
18.	He was admitted to the medical ward the following day, 3 November 2014. No medical cause of his hallucinations was discovered. Professor Parker saw him and believed that he was suffering first episode psychosis, secondary to cannabis use. He was commenced on appropriate medication (Respiridone) and on 5 November 2014 discharged into the care of his family in Darwin.
Second Admission

19.	However he returned to Hospital on 8 November 2014, this time to the Mental Health Inpatient Unit and remained for ten days.
20.	He had not been taking his medication and had been consuming alcohol with family at the Bagot Community. He said he experienced voices telling him to hurt himself. However he told staff at the Hospital he would never do that.
21.	By the time of his discharge on 18 November 2014 he was no longer having hallucinations and he thought the medication had helped him. He said he would continue to take it. He was discharged on Risperidone to be taken each night.
22.	He was assessed by the Katherine Mental Health Team on 28 November 2014. He said he was travelling to Lajamanu with his mother.
23.	In early December 2014 Kaitlyn, his partner, returned to Lajamanu. She was three months pregnant. She said Kwementyaye seemed to think she was the “bogey man”. He didn’t seem to recognise her.  She found that he was no longer the happy man she knew him to be.
24.	On 9 December 2014 he presented at the Lajamanu Health Clinic with his aunt. He requested more Risperidone. He hadn’t had any for some time and his Aunt indicated that he seemed good during the day but he was hearing “things” at night. Kwementyaye said he didn’t want to talk about it. He was given a script for Risperidone.
Third Admission

25.	On 12 December 2014 the Clinic and the Police were called by family after Kwementyaye went out of control. He assaulted his wife and cut his hand when smashing glass on the school bus. 
26.	He was found on the road with a bleeding hand. Initially he appeared compliant and subdued but while his hand was being washed, on the side of the road, he flicked the water and blood at Police. He was handcuffed and taken to the Clinic. He said he had voices in his head that were teasing him. 
27.	His mother said he hadn’t been taking his medication and it was reported that he had been drinking heavily.
28.	He was sectioned and evacuated to the Royal Darwin Hospital the following day. He told staff that he had struck his wife after being told by voices to do so and he said he was jealous. The voices told him his wife was cheating on him. He did not believe her denials.
29.	He was admitted to the Joan Ridley Unit as an involuntary patient and then transferred to the Cowdy Ward three days later. His medication was changed to a “depot” to be administered every four weeks. He also underwent further medical investigations but again no organic cause for his hallucinations was found. During the latter part of that admission his wife came to the Cowdy Ward to be with him. He was discharged on 23 December 2014.
30.	On 24 December 2014 the Katherine Mental Health Team assessed Kwementyaye once more. He said he planned to return to Lajamanu on 15 January 2015. However he returned earlier than planned.
31.	On 3 January 2015 his family called the Lajamanu Health Clinic. They said that Kwementyaye needed medication because he was hearing voices in his head. The Health Clinic nurse indicated that she had not received a discharge summary and attempted to contact Cowdy Ward to determine what medication he was on without success and then went to see him. He seemed calm and polite in the presence of Police. He said that he wanted tablets. He was given diazepam and Risperidone. 
32.	In evidence it was stated that there were two discharge summaries: The nursing discharge provided to the Clinic and the medical discharge that had taken about eight days to complete.
Fourth Admission

33.	On 11 January 2015 after Kwementyaye saw someone in the mirror that told him to assault his wife he was found by Health Clinic staff walking along the road at 9.15 pm. He agreed with the nurse that he wanted to go back to Darwin for treatment.  Police arrived and Kwementyaye was taken back to the Clinic in the Ambulance. He was sectioned, sedated and held overnight with the aid of Clinic staff and Police.
34.	The following day Kwementyaye was flown to Darwin for a mental assessment and involuntarily admitted to the Joan Ridley Unit (JRU). When assessed he said he had been experiencing the voices since his last discharge on 23 December 2014. He said the voices were speaking in Walpiri language. They voices were those of people in Lajamanu. They said his wife was having an affair. That made him upset and he said that is why he assaulted her.
35.	He said he needed the medication to be “a little stronger”.  He remained in JRU until the following day when at 11.00 am he received 100mg of Paliperidone in the right deltoid and was transferred to the Cowdy Ward on a trial basis. 
36.	He was said at the time to have little insight and wanted to go home. His risk of absconding was rated at 3 (“significant risk”). He was on 15 minute observations. He remained calm and polite throughout the day on Cowdy Ward. 
37.	The last time he was sighted was at 5.45 pm after which he scaled the fence in the court yard and made his way to the Bagot Community in Darwin. A side door near the security office without a self-locking mechanism was also found unlocked at about the same time.
38.	He saw family and told them he had run away from the hospital. Two of his family went to another house to call Cowdy Ward and the Police. He took an electrical cord and walked into an open area behind the house. He tied the electrical cord to a short rope attached to a branch of a tree, wrapped the other end around his neck and sat down, crossed his legs and put his hands in his lap. The cord was sufficiently tight that it impeded the flow of the blood to his brain.
39.	He was found the next morning between 6.00 and 6.30 am in that same position. He was deceased.
40.	Why he absconded and killed himself is not entirely clear. The evidence is that from 11.00am to 5.45pm on 13 January 2015 Kwementyaye had been calm and polite. There was no evidence at that time that he was hallucinating.  He did not between the time he absconded and his death consume alcohol or illicit drugs.
41.	Without the benefit of hindsight it is difficult to say that the decision to move Kwementyaye from the secure ward, JRU to Cowdy Ward was an inappropriate decision. He had been on Cowdy Ward previously, even as a voluntary patient and had not previously sought to abscond. His mental state was much improved and he had been given his medication.
42.	Moreover, Professor Parker provided evidence of the ongoing efforts to find the balance between a therapeutic environment and one that was sufficiently secure in Cowdy Ward. It is after all, a Ward in which both voluntary and involuntary patients are treated.
43.	Those efforts to find the right balance commenced after the death of Dale Vincent in October 2004 and have continued to date. The efforts have not been insignificant. In 2004 the Ward had multiple entry and exit points and no security. The very fact that to leave Kwementyaye did so over a four metre fence provides some appreciation of how different the balance had become a decade later.
44.	It might be thought the balance should have been even more toward security. Hindsight makes such calculations easier, but I accept that most clinicians would have believed that to do so would be at a cost to the therapeutic environment. 
45.	After the death of Kwementyaye the balance was reassessed and further changes made. Mental Health provided a solution, putting mesh on part of the fence so as to negate holding points, rather than making the fence higher or covering the outdoor court yard.
46.	The Mental Health Facility undertook a Root Cause Analysis in relation to his treatment and the circumstances of his absconding. Recommendations for improvements were made and actioned:
“1.	There was concern that there could have been more checks by the psychiatrist and better communication between the JRU Team and the Cowdy Ward teams in relation to the circumstances of Kwementyaye at the time of his transfer to Cowdy Ward. Accordingly a “Multidisciplinary Inpatient Ward Round” document was drafted and implemented in mid-2015;
2.	That document also makes up eighty percent of what would be found on a discharge summary. The intention is that on discharge the medical summary will be able to be provided promptly. It was said that the preparation of the discharge summary should occur within 48 hours of discharge.
3.	Works were also carried out to the fence so as to remove places for hand and foot holds making it more difficult to scale. Those alterations were only completed in April 2016. It was reported that no one had absconded over the fence in the short period between then and the hearing;
4.	A review of CCTV was commissioned and completed. Additional CCTV was installed giving visibility of the area in which the fence was scaled;
5.	A self-locking mechanism was installed on the door that was found unlocked; and
6.	Physical and Procedural Security Audit was commissioned and completed in May 2016.
7.	A new procedure for sending discharge summaries.  Professor Parker indicated that they are now sent by email to the Clinic practice manager and also a generic staff email address.”
47.	It is clear that the Top End Mental Health Service took the circumstances of Kwementyaye’s absconding and death seriously. The effort put into the self-reflection and necessary improvements is commendable.  I therefore make no recommendations.
48.	What was not so good was the time taken to advise the Coroner’s Office of the response to the death. True it was that much of the material only became available in the days and weeks prior to the hearing. However provision of the draft affidavit on the last working day before the inquest and provision of some of the material during the course of the inquest does little to assist in preparing for the inquest either by my Office, Counsel Assisting or other parties.
49.	Pursuant to section 34 of the Coroner’s Act, I find as follows: 
(i) 	The identity of the deceased was Dean Jigili born on 20 November 1991, in Katherine, Northern Territory, Australia. 
(ii) 	The time of death was between 9.30pm on 13 January 2015 and 6.00am on 14 January 2015. The place of death was under a tree at the Bagot Community behind House 52 in Darwin,  Northern Territory. 
(iii) The cause of death was self-inflicted hanging. 
(iv)  The particulars required to register the death: 
1. The deceased was Dean Jigili.
2. The deceased was of Aboriginal descent. 
3. The deceased was not employed at the time of his death. 
4. The death was reported to the coroner by the Police. 
5.	The cause of death was confirmed by post mortem examination carried out by Dr John Rutherford. 
6. 	The deceased’s mother was Maria Jigili and his father was Earl Gibson.

Dated this 11th day of July 2016.

		_________________________
	JUDGE GREG CAVANAGH
                                                                             TERRITORY CORONER