39 year old man with schizo-affective disorder under an emergency examination order stops breathing when his pyjamas were forcibly removed.

Inquest dates: 11 - 14 April 2016; 28 June 2016 Coroner: James McDougall Place: Brisbane Date of death: 12 September 2011

Issues for Consideration

  • Cause of death of Mr Coolwell.
  • Whether QPS acted appropriately in taking Mr Coolwell to the hospital under an emergency examination order.
  • Whether Mr Coolwell's transfer to the mental health unit was reasonable.
  • Whether the decision to and manner of placing Mr Coolwell into seclusion was appropriate.

Case Summary

On 11 September 2011 Mr Coolwell, suffering from a schizo-affective disorder, presented to the Queensland Police Service (QPS) wearing Superman pyjamas and appeared to be in mental distress, stating that he was ‘the Hulk’ and that he had been up all night battling ‘Superman’. He also claimed to be an undercover policeman.

Police took Mr Coolwell to Logan Hospital under an emergency examination order. He was placed under a temporary involuntary treatment order and admitted to the short stay unit (SSU) for assessment.

Mr Coolwell was transferred to the mental health unit on 12 September 2011. Shortly afterwards it was decided that he should be sedated and put into seclusion following an incident in which Mr Coolwell acted aggressively (though, it emerged in evidence, not violently).

Mr Coolwell remained in his Superman pyjamas throughout his hospital admission. It was noted in the Inquest Findings that Mr Coolwell likely placed great significance on those pyjamas as reinforcement of his long standing Superman persona.

Before moving Mr Coolwell into seclusion staff attempted to remove his pyjamas (as a safety precaution) which severely distressed Mr Coolwell and caused him to have a violent reaction. A struggle ensued. Eventually Mr Coolwell’s pyjamas were removed and he was left with a pair of “security linen” (which could not be torn and used by a suicidal patient as a ligature).

A short time later Mr Coolwell was found unresponsive and resuscitation attempts were unsuccessful.


QPS actions

  • The QPS determined that action should be taken under s34 of the Mental Health Act 2000 based on his presentation and their review of the Queensland Police Records and Information Management Exchange (QPrime) system.

Treatment at the SSU

  • Mr Coolwell was kept in the SSU because he had other medical issues to attend to (there was evidence he had been sedated, required oxygen and was obese).
  • Mr Coolwell was required to be restrained by security on two occasions of abscondment from his bed whilst at the SSU. After each of those occasions he experienced difficulty breathing and required oxygen therapy.
  • Mr Coolwell’s blood gases were analysed on the morning of 12 September 2011. He was noted to be hypoxic. Dr Chao considered that may have been due to administration of Midazolam and, as that drug dissipated in Mr Coolwell’s system the hypoxia resolved.
  • Dr Chao made an entry of “Continue psych admission psych – Not for transfer to Medicine at this stage”. This was interpreted by staff at the hospital as a clearance to transfer Mr Coolwell to the mental health unit.

Treatment at the mental health unit

  • A short time after admission the to mental health ward Mr Coolwell approached the nurses station seeking a cigarette. He was advised that he was not due for another. He ignored those instructions and entered the nurses’ area opening drawers and looking for cigarettes.
  • A duress alarm was sounded by one of the nurses.
  • It was decided that Mr Coolwell should be sedated and placed into seclusion. The reasons provided by the doctor making that decision were:

“patient aggressive and destructive towards hospital property cannot be contained in open ward of A0A20”

  • Instructions were given by the doctor to ensure observations were maintained of Mr Coolwell in 15 minute intervals and it was reiterated to nursing staff that there was risk of respiratory compromise due to his past hypoxic state, his obesity and chest infection.
  • Mr Coolwell was administered Olanzapine (an antipsychotic) and then, as a matter of course, was going to be put into security linen (that could not be torn). This caused a violent reaction in Mr Coolwell. He struggled and resisted to a point that force had to be applied by security guards. Peroneal nerve (leg) strikes were performed so that Mr Coolwell collapsed onto the floor. Staff managed to remove the pyjamas and left Mr Coolwell to put on the security linen himself.
  • Immediately after Mr Coolwell had been placed in seclusion the nursing staff became concerned as he appeared to be unconscious. A code blue was called and attempts made at resuscitation, but they were unsuccessful.

Cause of death

  • It was determined that the most likely cause of death was respiratory failure due to reduced blood gas transfer capacity in Mr Coolwell’s lungs, leading to cardiac arrest.


  • The police acted properly in relation to Mr Coolwell and the decision to take him to hospital under an emergency examination order was appropriate.
  • The Consumer Integrated Mental Health Application (CIMHA) database utilised during the triage process was of limited utility.
  • There may have been some confusion between medical and mental health teams as to whether Mr Coolwell was ready for transfer to the mental health ward.
  • The decision to transfer Mr Coolwell to the mental health ward from the SSU was premature.
  • The decision to place Mr Coolwell into seclusion was not in strict accordance with the requirements of the statute but was nevertheless a reasonable decision made in a reasonable attempt to comply with those statutory requirements.
  • The decision to remove Mr Coolwell’s clothing and change into security linen caused him great distress. However, it was understandable and arose out of concern for the patient’s welfare and risk of self-harm.
  • After MR Coolwell was placed in seclusion, he was kept under continuous observation and nursing staff responded quickly when they perceived the risk of a medical emergency.

Conclusions and Recommendations

  • The Coroner noted that changes to the Mental Health Act 2016 have fundamentally changed the use of seclusion.
  • The Coroner noted that a number of changes have been implemented and incorporated in the Inpatient National Standards Implementation Project following the Coroner’s review of the Metro South Hospital and Health Service.
  • It was recommended that the CIMHA system be reviewed in order to provide information summarising the mental health history of any patient that has been subject to an Involuntary Treatment Order.

Chronology of Events

Click here to view table