On 4 August 2014, the Coroners Court of Victoria released its finding in the inquest into the death of Frederick Joseph Williamson, a patient who had resided in the Secure Extended Unit of Austin Health since 1987.

In March 2008, Mr Williamson was found lying on the ensuite floor of his room with a plastic bin liner from his rubbish bin over his head.  At the time of Mr Williamson’s death, the police suspected he had placed the bin liner over his head, twisted it closed under his chin and lost consciousness.

While Coroner Spanos concluded that Mr Williamson’s injuries were not self-inflicted, the reasons and circumstances in which his death occurred could not be determined.  Coroner Spanos labelled the police investigation as “inadequate” and concluded that mistakes made by police at the scene were “irremediable”.

There were no adverse findings regarding the clinical management and care provided by Austin Health; however, Austin Health has since implemented various changes, including the use of paper (rather than plastic) bin liners, daily risk assessments for patients and increased medical staffing levels.

To view the findings, click here.