Gerard Stefaniw died on 21 October 2016 at the age of 63 years old at the Roy Fagan Centre. At the time of his death, Mr Stefaniw was an inpatient at the Centre under an order made by the Guardianship and Administration Board.

Mr Stefaniw instructed a solicitor in an attempt to have the order removed so he could leave the Centre. Mr Stefaniw committed suicide two days after being informed by his solicitor of an unfavourable cognitive impairment report. The Coroner considered it was not necessary or desirous to make any recommendations, as subsequent appropriate changes by the Centre had been implemented since Mr Stefaniw’s death. 

Background Facts

Mr Stefaniw suffered from cerebral palsy, hip dysplasia, severe degenerated hip disease, spinal issues and urinary and faecal incontinence. Mr Stefaniw also had a lengthy history of engagement with mental health services, suffering from a significant cognitive impairment. By early 2015, Mr Stefaniw’s self-care had deteriorated so much that he was suffering from malnourishment and living in squalor.

This deterioration in his physical and mental health, and consequent inability to care for himself, resulted in the making of an order by the Guardianship and Administration Board (the Board). A second order was made on 26 August 2016 that the Public Guardian act as Mr Stefaniw’s guardian in the following limited circumstances:

  • decisions concerning where Mr Stefaniw was to live whether permanently or temporarily;
  • consent to any healthcare that was in the best interest of Mr Stefaniw and to refuse or withdraw consent of any such treatment; and
  • the provision of support services to Mr Stefaniw.

Initially, Mr Stefaniw was accommodated at a nursing home, however his medical conditions necessitated three admissions to the Roy Fagan Centre.

Mr Stefaniw was deeply unhappy about being subject to the Board order and being accommodated at the Roy Fagan Centre. He sought advice from the Legal Aid Commission on 13 May 2016 with a view of challenging the order. His solicitor arranged for Mr Stefaniw’s cognitive functioning to be assessed by Dr Blake. Dr Blake reported that Mr Stefaniw was in need of a guardian and his decision-making was so impaired that the order was fully justified. Mr Stefaniw's solicitor met with him on 19 October 2016 to discuss the contents of the report. She subsequently discussed the report with one of Mr Stefaniw’s nurses and suggested it might warrant extra care or observation in case Mr Stefaniw became upset. The nurse did not act on this information of pass it on to other staff.

At approximately 6am on 21 October 2016, Mr Stefaniw was found naked and hanging by an electrical cord around his neck, tied to a cupboard in his room in the Roy Fagan Centre. The electrical cord belonged to an electronic PlayStation type device belonging to Mr Stefaniw. Mr Stefaniw had last been seen alive at 3.30am, when he was sitting on his bed watching television. It was not unusual for Mr Stefaniw to be awake at this time.


The Coroner found that Mr Stefaniw was a person held in care pursuant to section 3 of the Coroners Act 1995 (Tas) and therefore an inquest into his death was mandatory. This conclusion arose despite the fact Mr Stefaniw was not detained until the Mental Health Act 2013, as he was subject to the control of staff and detained within the Roy Fagan Centre against his will. Further, he had obtained a solicitor to challenge the Board order so as to enable him to leave the Roy Fagan Centre.

As a consequence of this Coroner’s finding, the Coroner was required to comment upon Mr Stefaniw's care, supervision and treatment. The Coroner concluded that the care, supervision and treatment was of an entirely appropriate standard, subject to one qualification. That qualification was that the nurse was apprised of reason to have concern on 19 October 2016 by the solicitor and he did nothing to pass that information on. The situation would have been materially different had staff been aware of the adverse report made by the solicitor to the nurse, and it is likely that an increased level of checking would have been undertaken. As to the cause of death, the Coroner found that Mr Stefaniw placed the electrical cord around his neck, but the Coroner could not be satisfied to the requisite legal standard that he did so with the intention of ending his life. This was because he had a history of undertaking actions designed to protest against perceived injustices and also given his level of cognitive impairment.


The Coroner found that the circumstances of Mr Stefaniw’s death did not require any comments or recommendations as the Roy Fagan Centre had taken appropriate steps to address the issues that arose from Mr Stefaniw's death. In particular, the Centre had provided staff within increased training in relation to the assessment and management of risk of self-harm. Additionally, steps had been taken to remove hanging points from various rooms on the wards.