The father of a 22-year-old man who died after absconding from a mental health unit says a coronial inquest is confirming the family's suspicions of a "broken system".
Key points:
- Jaxon Kinnane died after leaving a hospital where he'd been held on mental health grounds
- A consultant psychiatrist found Jaxon's death could have been prevented
- An inquest is looking into his death
Jaxon Charles Kinnane was transferred multiple times between custody at Casuarina Prison and involuntary care at the Frankland Centre over six months in 2020.
The Frankland Centre is a 30-bed forensic hospital at Graylands Hospital, providing inpatient mental health care to remand and sentenced prisoners.
After being released, he was voluntarily admitted to a mental health ward at St John of God Midland Hospital, where he was treated with antipsychotic and antidepressant medications.
He left the ward on October 9, and was found dead in the Swan River on October 13.
Outside court on the first day of a coronial inquest into Jaxon's death – which was granted by the court after applications by the family – Jaxon's father Murray Kinnane said he hoped the inquest would fix issues within the health and justice system.
"Our suspicions were confirmed that the systems are broken and treatments are very iffy, and some places don't talk to other places," Mr Kinnane said.
'Microchip' fears
The inquest's opening address noted Jaxon was "overwhelmed by his sudden release" from custody.
Jaxon's father expressed concerns to the hospital several times that his son had suicidal thoughts, and may abscond from hospital.
"Jaxon denied these thoughts when asked by staff and appeared to be only concerned about the microchip," the address read.
Jaxon had a fixated belief there was a microchip in his ear recording his movements and conversations, despite an MRI confirming that wasn't the case.
Jaxon requested to leave the hospital's mental health ward without an escort on October 9 to visit his father.
The request was granted despite neither of his parents being advised.
Jaxon did not meet his father, or return to the ward, and was found dead in the Swan River on October 13.
A post-mortem examination found Jaxon died by drowning, with the effect of drugs and a history of seizures contributing factors.
The inquest will examine issues relating to Jaxon's care in the months leading up to his death, including his treatment at Casuarina Prison, at the Frankland Centre, and finally at St John of God Midland's mental health ward.
The inquest's opening address noted a consultant psychiatrist reviewed the case – after applications for an inquest from Jaxon's family – which prompted the inquest.
"A consultant psychiatrist provided an independent opinion … the quality of Jaxon's mental health treatment and care was suboptimal and considered his death was preventable," the inquest's opening statement read.
'Very tormented young boy'
The first day of the inquest – more than three years after Jaxon's death – heard from clinical nurses at Casuarina Prison, where Jaxon was held in custody.
Nurse Colin McKnight described Jaxon as a "very tormented young boy", which prompted him and colleagues to attempt several times to transfer him to the Frankland Centre where he could receive more appropriate care.
"We have a backlog of prisoners that need to see psychiatrists and don't get to see them [at Casuarina]," Mr McKnight said.
"In November we were having to put people back into January to be seen – that's not, that's not right.
"I think there should be at least three days a week [when a psychiatrist is available], but that's not the case."
Jaxon was examined by a psychiatrist inside Casuarina and was described as agitated, anxious, distressed and presenting with psychotic symptoms, but denied suicidal ideation.
Mr McKnight noted how difficult it was to transfer some of these prisoners to facilities with more appropriate care due to a lack of beds.
"It's difficult – and that's an understatement – to get a patient from a prison to the hospital," he said.
Another nurse, Emma Tsakalos, admitted under questioning she did not know why in one instance Jaxon was not sent back to the Frankland Centre when he was refusing medications, despite recommendations to do so from the centre itself.
Jaxon's father described the emotional toll his son's death has had on his family.
"I felt completely devastated as a father, to lose my son, my only son," Mr Kinnane said.
"Unfortunately, it's affected my life, I no longer work … I don't know if I'll ever work again.
"But, I'm staying strong because I want to represent my son as best as I can, and of course my daughters, and my wife."
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