Above - Carole with husband Chris
Missing since: Tuesday 3
Last seen location: Read
Street Cooloongup WA
Year of birth: 1966
Age at time of disappearance: 50
Hair colour: Brown
Eye colour: Blue
On the afternoon of Tuesday 3 October 2017, Carole LIVESEY left Rockingham
General Hospital situated at 71 Elanora Drive, Cooloongup, WA prior to
discharge. Carole was last seen at approximately 2.30pm that day by staff at
the Salvation Army, on Read Street Cooloongup.
At the time Carole was wearing a light blue shirt and black pants. Her right arm
was in a cast, however it is likely that the cast would no longer be present as
it would have deteriorated over time.
If you have any knowledge concerning this
matter, please make an online report below or contact Crime Stoppers on 1800 333
000 You can remain anonymous if you wish and rewards are offered.
JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA
ACT : CORONERS ACT 1996
CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER
HEARD : 6 - 8 SEPTEMBER 2021
DELIVERED : 25 JANUARY 2022
FILE NO/S : CORC 921 of 2018
DECEASED : LIVESEY, CAROLE
Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH
I, Sarah Helen Linton, Deputy State Coroner, having investigated the
disappearance of Carole LIVESEY with an inquest held at the Perth Coroner’s
Court, Court 85, CLC Building, 501 Hay Street, Perth on 6 to 8 September 2021,
find that the death of Carole LIVESEY has been established beyond all reasonable
doubt and that the identity of the deceased person was Carole LIVESEY and that
death occurred on or about 3 October 2017 at an unknown place as a result of an
unascertained cause in the following circumstances:
1. Carole Livesey was a complex woman who lived an adventurous life with her
husband, Chris Lampard. They had achieved financial independence early in life
and used that financial freedom to travel the world together. They chose to live
a simple, sustainable lifestyle, often living ‘off the beaten track’. Carole and
her husband eventually found themselves in Western Australia, where Carole
established a successful housesitting business.
2. Unfortunately, for many years Carole had struggled with an eating disorder,
which worsened while she was living in Western Australia and was complicated by
symptoms of depression. Leading up to her death, Carole was diagnosed with
anorexia nervosa and major depression with suicidal thoughts.
3. Carole had been receiving medical treatment for these medical conditions
without much success for over a year, as she did not accept many of the
treatment recommendations. She was admitted to hospital, but found the hospital
environment distressing, so she persuaded her husband and doctors that she would
be best served by seeking treatment from home.
4. Mr Lampard attempted to support Carole as best he could, including caring for
her at home at her request, but her suicidal behaviour escalated to a point
where he accepted the only safe place for her was in hospital. Carole was
severely malnourished and medically unstable when she was involuntarily admitted
to Rockingham General Hospital for treatment on 7 September 2017. Carole was
admitted as an involuntary patient in the Mental Health Unit (Mimidi Park) at
the hospital, as it was determined she was unable to make reasonable and
informed decisions about her medical care.
5. While in hospital in September 2017, Carole struggled to comply with the
treatment and did not put on weight. Eventually she was required to have a
nasogastric tube inserted and steps were taken to generally restrict her
movements, in order to try to promote some lifesaving weight gain. After these
extreme steps were implemented, Carole began to put on weight, but she was
clearly very unhappy at having the control taken away from her. Carole made it
clear she wanted to go home. In the past, Carole’s husband had supported her
requests to be discharged. However, on this occasion he resisted her demands as
he wanted her to stay in hospital until she got well. This appears to have
caused Carole to become angry with her husband, and she began to confide in him
a little less than usual.
6. As she was starting to gain weight and improve, Carole was permitted a little
more freedom on the ward, although she still had a nurse with her at all times.
On 3 October 2017, while being pushed in a wheelchair on an escorted walk
through the hospital grounds, Carole unexpectedly jumped out of the wheelchair
and ran away from the hospital. When she had done something similar in the past,
Carole had immediately returned home. However, on this occasion, she did not.
7. Carole was found wet and distressed by a member of the public after
apparently attempting to drown herself in the ocean. Carole was taken to a local
Salvation Army centre for assistance. The Salvation Army staff tried to make her
comfortable and notified the hospital that she was there after noticing her
hospital tag. Staff from the hospital notified the police, who had gone to
Carole’s home in the expectation she would go there. The Salvation Army staff
were told the police were on their way, so they tried to keep Carole occupied.
Unfortunately, the local police were caught up with other matters, so their
arrival was significantly delayed.
8. By the time the police attended the Salvation Army premises, Carole had left.
Other than a few unconfirmed sightings in the following days, Carole has not
been seen again. She has not contacted her husband, or any other family member
since she disappeared on 3 October 2017. There is no evidence to indicate she
has come into contact with any government agency or sought help from any other
group, even though at the time she disappeared she had no money or
identification and only the clothes she was wearing.
9. On 27 July 2018, the Coroners Court received a letter from Carole’s husband.
He formally requested that an inquest be held into his wife’s disappearance, on
the basis he considered it likely she had died around the time she absconded.
10. The State Coroner considered Mr Lampard’s request, and a comprehensive
report prepared by the WA Police into her disappearance, and determined that
pursuant to s 23 of the Coroners Act 1996 (WA), there was reasonable cause to
suspect that Carole had died and her death was a reportable death. As a result
of that direction, an inquest was required to be held into the circumstances of
the suspected death.1
11. I held an inquest at the Perth Coroner’s Court from 6 to 8 September 2021.
As well as considering the evidence that would potentially establish that Carole
is deceased, the inquest also covered Carole’s medical care prior to her
disappearance, the circumstances of her absconding from the hospital, and why
the police did not attend the Salvation Army in a timely manner.
12. At the conclusion of the inquest, I indicated that I was satisfied beyond
reasonable doubt that Carole died on or about the date she absconded from
hospital, but I would need to give further consideration to what other findings,
if any, I might be able to make in relation to the circumstances of her death.
13. Carole was born in the United Kingdom and was one of seven children; she had
three brothers and three sisters. Carole met her husband, Chris Lampard, in June
1989 in Nottingham. Carole was working as a care worker at the time and studying
an arts degree in film and literature. They married in February 1991 and Carole
began studying a diploma in social work.2
14. In 1992, Carole’s husband transferred to Glasgow as part of his academic
studies. Carole was not initially keen to move, as she had moved a lot in her
childhood and she had made friends in Nottingham. However, she joined her
husband in Glasgow after a period of about three months and she eventually came
to enjoy living there. They bought a home and Carole became involved in
renovating it, as well as training as a fitness instructor. As part of her
training, she became very focussed on improving her own fitness and began
cycling, running, swimming and attending yoga classes daily. This intensive
early fitness regime may have been a precursor to the eating disorder she was to
15. In May 2003, the couple sold their house in Glasgow and used the proceeds to
buy two flats in Manchester. They went to live in Manchester briefly, before
moving to New Zealand in November 2003. Their eventual plan was to move to
16. The couple settled in Christchurch and Carole’s husband got a job with the
district health board, while Carole initially worked in a social work job. They
were living in a tent on a campsite for the first few months before they began
housesitting for about a year. In June 2006 they began travelling around New
Zealand, still housesitting at times and also as part of an organisation where
they worked on organic farms for accommodation and food.5 If these were not
available, they would simply put up a tent and camp. Mr Lampard described their
lifestyle philosophy as focussed on sustainability and trying to be very ‘green’
in their thinking. He stated,6 We have never found a house that was small enough
for our needs, any furniture we owned was from garage sales; we had very little
17. In November 2008, Carole and her husband followed their plan and moved to
Australia. They spent time in Sydney and Torquay. They were in Victoria during
the time of the Black Saturday bush fires in February 2009, which they both
found so distressing that they decided to return to New Zealand for a while. In
about October 2011 they returned to Australia with nothing more than a backpack
each. They travelled around Australia and eventually settled in Western
Australia in February 2012.
18. Mr Lampard was inclined to stop travelling at this stage and settle down in
one place. He had become very interested in gardening and perma-culture and he
wanted an opportunity to see his gardening projects develop to maturity. Mr
Lampard described this time as a “complicated period”8 in their relationship. Mr
Lampard recalls that Carole had started to get thin by this stage. They had both
always been fit and well but Carole had been wanting to control the amount of
food she consumed for a number of years. She had eventually started drinking
protein shakes, rather than eating food. She also became increasingly worried
about money, despite the fact that they had been financially secure for many
years due to sound investments, and they lived frugally. Mr Lampard considered
Carole’s concerns about money were not reasonable, given their sound financial
19. They eventually bought a house in July 2013 in Tuart Road in Mandurah.
However, in April 2014 they started renting out this house and returned to doing
housesitting and travelling. They travelled through the south west of Western
Australia, before heading across the country to South Australia, Victoria and
Tasmania. They returned to Western Australia in 2015 and continued housesitting
in various locations in Mandurah, with Carole managing it as a paid ‘house and
dog sitting’ business. Carole often did the housesitting alone, while her
husband remained at their home tending the garden.
20. Carole had been a gym member for some time, but she began more intense
weight training in combination with protein powders around this time.
21. In August 2016 they sold their Tuart Road house in Mandurah to purchase a
different house in Exchequer Avenue, Mandurah. Carole had been determined that
she wanted the house, but after they bought it she became preoccupied with a
belief they had paid too much for it. After they moved into the house, they also
found the road was too busy and too noisy for their liking.
22. Around February 2017, Carole started to cancel her scheduled house sitting
bookings. She became depressed and appeared to lose her sense of purpose. They
bought another property in Halls Head in March 2017 and Mr Lampard was hopeful
this might help her, as she was not happy at their other house, but Carole was
said to have still felt unsettled and expressed a dislike of the new house in
Halls Head. It required renovation but Carole was not interested in renovating,
despite having done renovating work in Glasgow. She also didn’t feel comfortable
with the neighbours and didn’t like the fact that the house was in Halls Head,
which added to the distance she had to travel on her bicycle on her usual
23. As Carole became increasingly ill, she became disconnected from her husband
and lost her joy for life. She was struggling to get out of bed and to motivate
herself, and she appeared physically weaker than before. Carole had been
volunteering for a number of years at two libraries and a breakfast club at a
local church, but she gave up her volunteering roles, started winding down her
housesitting business and “emptying her life of the things she used to do.”14
She even stopped gardening at home and became increasingly isolated.
24. Carole had previously suffered from Raynaud’s disease, a circulatory
condition, and she had also suffered from ongoing gum disease and associated
dental issues. However, this was the first time she had ever shown signs of real
ill health. Mr Lampard began to observe marks and scarring on Carole’s body,
which he thought was possibly from self-harm. In late 2016 she began to also
show signs of possible depression and seemed preoccupied with the possibility
she might develop a terminal illness and die young. Her husband noticed an
increase in her drinking around this time and her behaviour became erratic,
often involving verbal abuse towards him. When she was drunk, her obsession with
the failure of their Exchequer Avenue house purchase would also consume her. She
would blame her husband for not stopping her from making the decision to
ROCKINGHAM HOSPITAL ADMISSIONS - MAY 2017
25. Mr Lampard reported that his wife had been controlling her food intake for
six to seven years, and had been voicing her desire to die for about 12 months,
before she had her first hospital admission. About a week before her first
hospital admission, Mr Lampard came home in the afternoon to find Carole had
left a suicide note on the dining table. The note said she had gone to McLarty
Road in Halls Head. He knew it was an empty holiday home that had a spa pool. Mr
Lampard was very concerned and went out on his bicycle to look for her. As he
rode towards the property, Carole rode towards him from the opposite direction.
He began crying and shaking in relief. She told him she had changed her mind and
gone to the library instead.
26. On 5 May 2017 Carole self-presented to the Peel Community Mental Health
Service (Peel Community Health) with a report of low mood and suicidal thoughts.
She was escorted to the Emergency Department, but left before she was assessed.
27. The following day, being 6 May 2017, staff from Peel Community Health
conducted a home visit. Carole stated she had been feeling low since moving to
Halls Head in March and had recently made an attempt to commit suicide by
dropping the sofa on herself. She had also planned to drown herself in a vacant
property’s pool. Carole was told she would need to go to hospital for
psychiatric assessment. She was driven to Rockingham Hospital by her husband so
she could undergo psychiatric review.
28. After being reviewed, Carole was admitted to the general medical ward with a
diagnosis of anorexia nervosa, hyponatraemia (low sodium level) and suicidal
ideation. Carole admitted to restricting her calorie intake, purging several
times per day and exercising excessively. She had a low BMI (13.5), was
malnourished and had some metabolic instability. She was commenced on a high
protein, high calorie diet and was medically stabilised. She had someone
allocated to watch over her due to her risk of suicide. Mr Lampard recalled she
found it difficult having someone with her all the time. She was also unhappy
with the food they were offering, as well as the amount of food they wanted her
29. The plan was apparently for Carole to be transferred to the mental health
ward once she had been cleared for transfer by the medical team. On 12 May 2017,
after almost a week in hospital in the general ward, and prior to being admitted
to the mental health ward, Carole absconded from the hospital while on an outing
in the grounds. Her husband recalled she ran off while being escorted out in the
fresh air in a wheelchair. The lady who was pushing her was pregnant, so when
Carole took the opportunity to run, the lady was not able to chase her. The
hospital telephoned him around midday to tell him that she had absconded.
30. She was placed on a Form 1A under the Mental Health Act 2014 (WA), which is
a referral for examination by a psychiatrist. Police were notified, so that she
could be brought back into the hospital for assessment once found.
31. At about 3.00 pm, Carole turned up at home. She told her husband she had
sneaked away through the bush and caught a lift from someone by hitchhiking. She
had come straight home. Carole had her phone with her, so her husband asked her
why she had not responded to his text messages. She told him she didn’t want to
give away her location as she was aware the police were looking for her. Mr
Lampard wanted to help her and sympathised with her fear of being picked up by
the police, so he gave her money and a passport. She left the house with the
intention of cycling to a friend’s home, although she never arrived there.
32. Carole returned to her home on evening of 14 May 2017. She had exchanged
some texts with her husband while she was in hiding, but it seems she had not
disclosed to him her whereabouts. When she returned home she told him she had
slept rough by breaking into a beach shack in Melrose Beach, near another house
that she had housesat in the past. She asked her husband if he would “let her
stay at home and starve herself to death.” 22 He told her this couldn’t happen
and persuaded her to return to hospital. She was taken back to the hospital by
her husband that evening.
33. On her return to Rockingham Hospital on 15 May 2017, Carole was assessed by
Consultant Psychiatrist Dr Oladele Ojo. The notes indicate Carole displayed some
insight into her condition and was polite, cooperative and agreeable to being
admitted for treatment to increase her weight to a safe level. Accordingly,
Carole was admitted as a voluntary patient to the open ward of the psychiatric
34. The plan for Carole’s care at that stage was for her to be weighed daily,
provided with a diet plan by a dietician, her food and fluid intake to be
recorded daily and her urea and electrolytes to be within normal range. In terms
of her supervision, she was to have six hourly observations during the day time,
as well as general visual observations every hour, and was able to have escorted
leave within the hospital grounds with staff or her husband.
35. Mr Lampard stated that he and Carole “found the mental health ward
terrifying.”26 He also expressed the opinion the mental health ward staff
“looked really loose in comparison to the medical ward.”27 Mr Lampard visited
her every day for four days and he stated both he and Carole pushed for her to
be released back home with outpatient care follow up.
36. Carole’s doctors were aware she felt the hospital environment was causing
her distress. Dr Ojo stated that Carole constantly reported she did not want to
be in hospital as she didn’t like the food or the environment and felt she would
do better at home. Meetings were held with Carole and her husband regarding her
treatment goals, which included a goal weight of 50 kg, and she confirmed her
willingness to eat a healthy and balanced diet at home. She also agreed to be
followed up in the community with her GP and the community mental health team.
Carole’s GP had advised they had a dietician within their service who could
assist. With the support of her husband and GP, Carole was eventually discharged
home on 19 May 2017. By that stage, her blood tests were no longer indicating
abnormalities that required intervention in hospital but I note she weighed only
40.12 kg, 10 kg below the goal weight.
37. On 25 May 2017, a post discharge follow-up home visit was conducted by Peel
Community Health. Carole reported she was doing well, but had not yet seen her
GP or dietician. She said that Mimidi Park was not the place for her and that
the food was horrible. She was noted to be guarded about her mental state but
she claimed the crisis situation was over. Carole said she no longer required
the input of the mental health team. Carole was subsequently discharged from the
Peel Community Health Service as she declined any further follow-up.
30 JUNE TO AUGUST 2017
38. It appears Carole continued to suffer a fluctuating mental state in the
following months. Mr Lampard stated that she was attending her doctor,
psychiatrist and dietician and he felt she was making some progress and appeared
to be on the road to recovery.31 However, Mr Lampard also reported that on 13
June 2017 they went camping together up north for a change of scene and Carole
was behaving oddly and being verbally abusive towards him. The level of stress
in their relationship continued to mount as they headed further up north. While
they were staying at the Nanga Pools resort, Carole reportedly got up in the
night and tried to drown herself in the hot pool. They talked about this, and
her other suicide attempts, and Mr Lampard formed the impression she was not
serious in her attempts. Nevertheless, they decided to cut short their holiday
after this incident and returned home at the beginning of July.
39. After their return home, there was an incident when Carole was behaving
erratically at a friend’s house and she went out and did not return. Mr Lampard
went to look for her and found her staggering towards the estuary. Mr Lampard
later found out she had got hold of some temazepam tablets, ground them up and
consumed the whole packet. He took her home and put her in a hot bath. It does
not seem she suffered any long-term ill effects from the medication overdose.
40. Carole had been a patient of the Murray Medical Centre in Mandurah since
2013. On 5 July 2017, Carole consulted Dr Hwee Kim Toh at the Murray Medical
Centre in relation to her eating disorder. She was accompanied by her husband.
Carole reported cycles of binge eating and then feeling guilty afterwards. Her
mood and motivation were low but her sleep was generally good. She denied any
suicidal thoughts or ideation. Carole said she felt that stress from her recent
move had possibly contributed to her symptoms. It was recorded that her weight
had dropped below 40 kg, where it had previously been maintained at about 45 kg.
She admitted exercising excessively and restricting her food intake. Dr Toh
referred her back to Peel Community Health and discussed a possible referral to
a psychologist for cognitive behavioural therapy (CBT). He also ordered some
basic blood tests and arranged to review her the following week.
41. Dr Toh’s referral to Peel Community Health was to request an assessment as
he believed Carole had worsened since her discharge from hospital and had
associated low motivation and increased alcohol consumption. It was queried
whether she had underlying depression or a mood disorder.
42. The Peel Community Health notes record an acknowledgment of the GP referral
on 6 July 2017. A Senior Social Worker from Peel Community Health visited Carole
at home on 9 July 2017. Carole indicated she would prefer assessment to be done
in the clinic, and she agreed to attend the outpatient clinic the next day.
43. When Dr Toh reviewed Carole on 10 July 2017, she reported she was feeling
slightly better, had started bike riding again and was planning to start
housesitting again. She admitted to alcohol binges, stating that drinking helped
her take her mind off her worries, but said she had reduced her consumption over
the last few nights. Her blood tests were unremarkable other than showing mild
hyponatraemia. He arranged for more blood tests to be conducted in a few weeks’
time. They discussed a psychological referral again, but Carole indicated she
would prefer to wait until she had seen Peel Community Health.
44. Carole called in to Peel Community Health that same day, as previously
arranged. She was booked in for a formal appointment for 19 July 2017. However,
she failed to attend this appointment. Mr Lampard rang the service on 24 July
2017 and requested another appointment for Carole. An appointment was booked for
2 August 2017.
45. Carole returned to see Dr Toh on 26 July 2017. She reported fluctuating mood
since her last review. She also reported occasional suicidal thoughts but no
plans or attempts. She had started her housesitting job again but was still
feeling hopeless and lost. She said she had been attending Peel Community Health
and was booked in for review the following week. Dr Toh encouraged her to attend
the appointment for ongoing management of her mental health. He again discussed
referral to a clinical psychologist and they also discussed a safety plan, with
Carole advised to present to the ED at Peel Health Campus if she felt unsafe.
Follow up was planned for the following week.
46. On 2 August 2017 Carole was assessed by the triage nurse at Peel Community
Health. She gave a history of having an eating disorder for approximately 30
years and she was generally able to maintain her weight between 45 and 50 kg
with no physiological consequences. However, she had recently been binge eating
and put on 2 kg. She told the nurse since her hospital discharge she had felt
unsupported. She felt her husband had become more distant and withdrawn from her
to protect himself. Carole reported she had been on a six week holiday with her
husband but said they had returned early due to tension in their relationship.
She was spending a lot of time in bed, binge eating and drinking up to a litre
of wine a day, and admitted to having suicidal thoughts but denied any actual
plans or intent. Carole was noted to be very underweight and wearing soiled
clothes. An appointment was made for Carole to be reviewed by a psychiatrist as
the nurse had the impression Carole had anorexia nervosa and depression and
would benefit from being commenced on an antidepressant.
47. Carole presented to Dr Toh for follow up, as planned, on 3 August 2017. She
reported that she wanted to join a gym again as she felt socialising with other
people might help her mood. Carole reported that she was seen by the triage
nurse at Peel Community Health and was awaiting assessment by a psychiatrist.
She agreed to referral to a psychologist and a mental health care plan was
prepared to enable this. Dr Toh suggested follow-up in a few weeks’ time.
48. Carole was reviewed by Dr Ojo at the psychiatric outpatient clinic on 29
August 2017. Dr Ojo prescribed antidepressant medication and discussed the risks
and benefits of the medication with Carole. Dr Ojo also provided information
regarding a local dietician.
49. On 30 August 2017, Carole saw Dr Toh again to arrange referral to a
dietician, as requested by Dr Ojo. She advised she had also been commenced on
the antidepressant fluoxetine by Dr Ojo and had a follow up booked for two
ROCKINGHAM HOSPITAL ADMISSION – 7 SEPTEMBER 2017
50. On 1 September 2017, Carole attended Peel Community Health for review. She
indicated she was still considering whether to start taking antidepressants.
Carole indicated she did not believe the medication was going to help and
considered her mood would be suitably elevated if her nutrition was treated. She
was given some education about antidepressants, but it was noted Carole was
quite strong in her views. She was agreeable to receiving psychological input
from the psychology team at Peel Health and agreed to attend a follow-up
appointment on 5 September 2017. Carole then cancelled this appointment and was
offered another appointment for 8 September 2017.
51. On 6 September 2017, Carole drank half a bottle of gin and became drunk. She
threw food around the kitchen and tipped some of Mr Lampard’s belongings onto
the garage floor. He cleared up the mess while she continued to drink. She then
got a chair and belt and told him she was going to try and hang herself in the
garage. He stopped her by taking away both items. Carole then got on her bicycle
and rode away while shouting abuse at him. About an hour later, she returned in
an injured state. She told Mr Lampard she had been to the community garden and
tried to gas herself but had passed out from the fumes and hurt her arm and
ankle when she fell. Carole was still very drunk and she spoke about how unhappy
she felt about all the moving she had done in her childhood. She said she did
not want to live.
52. Mr Lampard and Carole made an appointment to see Dr Toh at the Murray
Medical Centre the next day. They went to the appointment on 7 September 2017
together. Mr Lampard saw Dr Toh by himself first and told him about Carole’s
suicide attempts. Dr Toh recalled he mentioned three attempts, involving
doxylamine, alcohol and gas. They were then joined by Carole at the doctor’s
request. She reported she had attempted suicide the previous day by drinking
half a bottle of gin and then hooking herself up to a barbecue gas bottle and
placing a plastic bag over her head in the Mandurah Community Garden. In the
process, she had fallen over and injured her right arm and left ankle. Dr Toh
contacted the triage nurse at Peel Community Health and Carole was advised to
present to the clinic for review.
53. Carole was assessed at Peel Community Health Clinic later that day in the
company of her husband. She was noted to be low in mood, flat in affect and
dishevelled. She admitted feeling hopeless and overwhelmed by her eating
disorder. She also admitted attempting suicide the previous day. She had no
protective factors and was considered a high risk of suicide. Carole said she
had a current plan to drink alcohol and drown herself in the ocean while laden
with bricks. Carole declined voluntary admission for psychiatric treatment in
hospital. She was felt to be displaying limited insight and diminished capacity
due to chronic starvation, so she was placed on a Form 1A under the Mental
Health Act and sent involuntarily to Rockingham Hospital ED for assessment. Mr
Lampard recalled Carole was very angry and surprised about being ‘sectioned’ and
sent to hospital. She refused to allow him to go with her.
54. Carole was admitted as an involuntary patient to the locked ward at the
Mimidi Park Mental Health Inpatient Unit at Rockingham Hospital. She was placed
on 15 minute observations and a one-to-one nursing special overnight, due to her
level of risk.48 Her physical observations were monitored four times a day and
she was prescribed thiamine and multivitamins. Carole was not keen to be
hospitalised and appeared ambivalent about her recent suicide attempts. After
she was psychiatrically assessed on 8 September 2017, Carole was placed on a
Form 6A Involuntary Treatment Order. At the time, it was noted Carole refused to
follow medical management for her fractured foot and was a high risk for
absconding and impulsivity.
55. Carole was referred to the Fracture Clinic. She was fitted with a Controlled
Ankle Motion (CAM) boot and a wheelchair was provided to avoid weight bearing,
but Carole refused any intervention for her foot injury. She said she wanted to
walk, as it gave her something to do and would likely help her to lose weight.
When Dr Ojo reviewed Carole on 11 September 2017, she was not wearing the CAM
boot. She stated her mood had lifted but felt being in hospital was not good for
her mood. Dr Ojo explained to her that there were concerns she had not been
engaging with community health services and not taking her antidepressant
medication. She asked why she was on a locked ward and she was told it was due
to her suicide attempt. She denied she was suicidal and left the interview room.
56. On 11 September 2017 a MET call was made after Carole fainted. She was
transferred to the medical ward, where she was diagnosed with chronic
hyponatraemia, most likely as a result of SIADH (syndrome of inappropriate
antidiuretic hormone secretion). She was given salt tablets and antibiotics for
a probable chest infection and transferred back to the psychiatric ward the
57. Carole saw the dietician, Ms Melinda Wright, for the first time on 12
September 2017. Carole was assessed by the dietician as having severe
malnutrition. Ms Wright was aware of Carole’s long history of disordered eating
and excessive exercise routine, as well as her previous hospital admission in
May. The fact that Carole had not followed the treatment plan on discharge,
including only seeing a dietician once, indicated to Ms Wright that Carole was
not keen to get better and did not appreciate her need for treatment.
58. Ms Wright recalled Carole was intelligent and asked questions and was not
difficult to engage with as a patient. Ms Wright indicated the goals, from her
perspective, was to get Carole medically stable, as she was experiencing medical
issues such as hypoglycaemia and postural tachycardia due to her low bodyweight.
She was commenced on a refeeding programme to slowly increase her weight with a
controlled eating plan, including supplement drinks and foods.
59. On 13 September 2017 the team discussed commencing Carole on an
antidepressant, but she was not keen due to fears of weight gain. She was also
non-compliant with wearing her CAM boot for her ankle injury and non-compliant
with eating her meals.
60. On 15 September 2017 Carole refused to see the treating team without a
mental health advocate present. She was suffering with episodes of low blood
pressure, low glucose levels, postural tachycardia and bradycardia which needed
to be stabilised. A weight goal of 45 kg was set. Carole was to undergo daily
blood tests and ECG’s and was allowed access to the open ward with a one-to-one
nursing special in place. This was successful, and Carole returned to the locked
ward without incident.
61. On 18 September 2017 Carole had a medical review, with a new cast placed on
her right arm and a diagnosis of a non-displaced anterior tibial fracture in her
left ankle, which required her to continue to wear the CAM boot.55 From that
date, visual observations were reduced to half hourly after a discussion between
Dr Ojo and nursing staff. This indicated she was showing improvement.
62. On 20 September 2017 there was a meeting between Dr Ojo, the medical team,
Carole, her husband and a mental health advocate. Carole revisited her history
and reported she first began experiencing suicidal ideation in April 2016, but
did not attempt suicide until March 2017. She denied any current suicidal
ideation and indicated she did not want to stay on the locked ward. Carole said
she wanted to be discharged into the community, or at least transferred to the
open ward. It was agreed she could be transferred to the open ward, but with a
one-to-one nursing special and strict management plan in place, as her
physiological parameters were still unstable. Carole was also granted permission
to attend the group occupational therapy sessions on the open ward if she wished
to do so.
63. Carole’s physical condition continued to be monitored and it was noted she
was not compliant with eating meals and taking nutritional supplements that were
prescribed to her, which resulted in her not gaining her weight and remaining
malnourished. She also remained medically unstable, with ongoing issues
associated with low body weight.58 As a result, on 21 September 2017 Dr Ojo
decided that Carole needed to have a nasogastric tube inserted to administer
feeds.59 There was evidence given that this is not uncommon for eating disorder
patients admitted due to being severely malnourished.60 However, Carole was
reported as stating she was a bit shocked that this was being considered as she
thought she had been making good progress.
64. The dietician, Ms Wright gave evidence that she believed Carole did attempt
to comply with her treatment plan, to the best of her ability, but there were
difficulties with Carole’s level of compliance that were related to her eating
disorder. In particular, she struggled to consume all of the foods and drinks on
the meal plan, due to an intense fear of losing control and gaining weight.62 Ms
Wright indicated that when the body is at a low body weight and in starvation,
the person may not have the full ability to appreciate or be self-aware of the
severity of their condition as their cognition is affected. However, Ms Wright
did try to inform and educate Carole as to what they were doing, and why. It had
become very clear to the dietician that Carole was struggling to be compliant
with her meal plan, despite education and encouragement, which had led to the
introduction of the nasogastric tube.
65. Carole was documented on 22 September 2017 as being disgruntled with her
treatment plan and reported being unhappy that her control had been taken from
her. She also said she would prefer a female one-to-one nursing assistant, but
was informed there was only a male assistant available at that time.64 Later
that day, Carole was transferred to the open ward, still with a nursing special
so Carole could be kept in constant visual observation. Attempts to find someone
to insert the nasogastric tube were unsuccessful on 22 September 2017. On 23
September 2017 the nasogastric tube was finally inserted. While Carole was not
keen to have the nasogastric tube inserted, she did not resist it.
66. The ongoing treatment plan was to stabilise Carole medically first and get
her weight stable, then treat her depression and work on a plan for
psychological input, such as cognitive behavioural therapy.66 The key aim from a
medical point of view was still to increase Carole’s weight to a base weight of
at least 45 kg before they would consider discharging her home. In order to help
Carole increase her weight, the medical team tried to limit her physical
activity as well as using the nasogastric tube to feed her. Carole was a very
active patient, so she was not happy to have her movements restricted. The
dietician also worked with Carole to help develop a nutritional plan and ensure
that Carole did not experience re-feeding syndrome (a potentially fatal shift in
fluids and electrolytes that can occur following reintroduction of nutrition in
67. In terms of treatment for her depression, Carole had been resistant in the
past to taking antidepressants as recommended. It was felt that Carole’s
depression stemmed from psycho-social stressors, and not just her eating
disorder, but given she would not cooperate with recommended treatment, the
focus was on improving her nutrition at that stage.
68. As for psychological input, Dr Ojo indicated that the best treatment for
anorexia nervosa is to get to the core of the fundamental issue, which is one of
body image. Carole’s severe malnutrition, and its effect on her ability to
comprehend and reason, meant the focus in hospital was to rehabilitate her
nutritionally to the point that therapy could then be used to address “the
underlining distortion in her pattern of thinking.”
69 However, Dr Ojo explained that the ongoing psychological therapy that would
be required to achieve this aim was not able to be provided at Rockingham
Hospital due to limited resources. Dr Ojo was, therefore, intending that Carole
would be encouraged to seek private counselling in the community once medically
stabilised and discharged.
70 Dr Ojo did not see Carole again after 21 September 2017 as he went on annual
leave. 69. Carole was reviewed by a Psychiatric Registrar and other medical and
allied health staff, together with her mental health advocate, on 28 September
2017. She had brought a list of questions and wanted to know how long she would
remain in hospital. She was told she was improving, but she still had postural
tachycardia, which indicated medical instability, so they could not give her a
timeframe for when she might be discharged. Carole was told she would remain on
the nasogastric tube until she was stable, despite her request to return to
eating normal meals. Although it was not usual practice for an eating disorder
patient to be told their weight goal, as this might need to be reviewed, it
appears Carole had become aware that her goal weight was 45 kg and she wanted to
know what the plan was, given she was near her target weight. It was explained
to her that her cast weighed approximately 1kg, which needed to be factored in
to her weight goal. Also, her weight was fluctuating, which indicated fluid
shifts, and that had to be factored in. Carole seemed unhappy with this response
and made it clear she was not keen to put too much weight on.71 70. Carole asked
why she did not have access to a psychologist. She was told there was no
psychologist available and she would need to consider a private psychologist. Mr
Lampard asked about the possibility of an external counsellor coming onto the
ward. The team were unsure if this was allowed, so they indicated they would
need to check, but it does not appear that this progressed during her admission.
71. Dr Ojo noted in his evidence that psychological support was provided by all
of the staff in their interactions with Carole, validating her distress and
feelings and providing education, but acknowledged that she did not receive
structured psychological therapy. This was because there were no psychologists
available at that time, but Dr Ojo also observed that it is extremely difficult
to provide structured psychological therapy to someone in Carole’s malnourished
state. Therefore, in his view, she was not ready to engage in structured
psychological support at that stage, even if a psychologist had been available,
and Carole would not have been ready until her weight increased and stabilised
at a level that made her amenable to such treatment.
72. It is apparent Carole was unhappy with the outcome of the meeting and her
husband expressed some concern to staff about how angry she appeared. He was
told that the way Carole was acting was expected for a patient with anorexia
nervosa. He was given some patient information about starvation syndrome to help
explain further. Mr Lampard was also told that after Carole was discharged she
would need a private psychologist and private dietician, with the best options
available through Hollywood Hospital or the Swan Institute.
73. Mr Lampard indicated he had decided around this time that he would have to
suffer with making Carole unhappy at times if it was for her best long term
good. He spoke to the staff at the time and acknowledged that during the last
admission he had advocated for her discharge. However, everything had gone
downhill in the three months after she went home, so he was keen for her to stay
this time for as long as required to get well.
74. This was a significant change in their relationship, as previously Mr
Lampard had only done what Carole wanted in terms of her treatment. As a result
of his decision, he was not supportive of her repeated requests to get her
released. This made her very angry with him.
75. On 29 September 2017 Carole had another psychiatric review with Psychiatric
Registrar Dr Touyz. She asked the same questions she had asked the previous day
regarding her length of stay and duration of her nasogastric tube. Carole
expressed the view the information about the need for her vital signs to be
stable was not consistent with information she had received previously. As a
result, she said she felt betrayed and could not trust the staff. Carole was
encouraged to ask the team about these issues the next week, as her assessment
was ongoing, and she was reassured that things would change as she improved. A
specific note was made in the psychiatric plan that she was not to have leave
over the weekend.
76. Carole made it clear to nursing staff over the following days that she was
unhappy to be remaining in hospital as an inpatient and indicated she was
getting despondent as she felt there was nothing to do. She was not interested
in the occupational therapy groups or socialising with her peers. She enjoyed
reading, but was becoming bored just reading and not doing anything else.
77. On 1 October 2017 Mr Lampard spoke to Carole on the telephone. He mentioned
he was thinking of visiting. Carole told him not to and put the phone down,
which made it clear to him she was still angry with him.78 Mr Lampard went to
the hospital to visit her anyway as the hospital staff had asked him to bring
her some warm clothes. At the time, she was only wearing her hospital gown and
getting cold and shivering. The staff were concerned this was slowing her weight
gain. Ms Wright explained that some eating disorder patients will underdress for
the weather, “with the goal of keeping their metabolism revved up to burn more
calories in keeping warm, which is to help restrict weight gain.”
78. Mr Lampard brought in some clothes and some library books. Carole appeared
convinced the clothes would not fit as she was obsessed with how much weight she
had put on. Carole also made it clear she was very angry with her husband. She
had the nasogastric tube in at that time and she told him she had been informed
she was not getting it out soon. Carole told Mr Lampard she believed she was
being asked to eat too much and didn’t like being watched all the time. During
this conversation, she also said that she believed she could climb over the
fence if she wanted to, even though she still had a plaster cast on her right
arm and boot on her left ankle. Mr Lampard gave evidence he felt this was
bluster and did not take her seriously, so he didn’t raise it with the hospital
79. While Carole was talking to her husband, they were joined by a mental health
nurse. It appears this was after the discussion about her climbing the fence.
The three of them talked about Carole getting some time out of the ward on a
supervised excursion. Mr Lampard said he did not disagree with that idea as it
was indicated the excursion would be supervised. He continued to visit with
Carole for a while longer and towards the end she warmed up a bit towards him.
However, she was still upset as she noted other patients were leaving the ward
but she was not permitted to leave.
80. Mr Lampard had been keeping custody of his wife’s phone for a few days as he
had required it to do their tax return. He returned the phone to her during this
visit. He left the hospital between 2.00 pm and 3.00 pm.82 This was the last
time Mr Lampard saw his wife. He gave evidence that during this visit his
impression was that she was not sane and not making a great deal of sense. She
was still obsessing about their finances and was angry and aggressive towards
81. Mr Lampard stated he had developed some reservations about Carole’s care at
the mental health unit and she had made it very clear she was unhappy to remain
there. Mr Lampard gave evidence he was concerned for Carole’s safety and had
little confidence that the Mimidi Park could keep her safe and stop her from
committing suicide.84 He had started to explore other options and realised that
she could get private health cover that would allow her to be treated at
Hollywood Private Hospital. Mr Lampard signed up for the cover, which included a
two month waiting period for psychiatric care. He told the hospital staff what
he had done. They were supportive of his decision and stated it would increase
the range of options for helping Carole.
82. On 2 October 2017 Carole’s weight had increased to 44.5 kg and her
observations were stable, except for ongoing postural tachycardia. She was still
only wearing a nightie and told the dietician, Ms Wright, this was because she
had no clothes that fitted her, but Ms Wright thought it was more consistent
with her wanting to continue underdressing for the weight gain benefits.86 Ms
Wright noted Carole was more medically stable and they discussed her transition
back to an oral diet and the expectations for her meals. It was clear to Ms
Wright that Carole was very focussed on being discharged as “she just wanted not
to be there,”87 but no indication that she was feeling suicidal. Ms Wright
planned to review Carole again three days later, but Carole absconded before
83. Carole told medical and nursing staff on 2 October 2017 she was worried she
was gaining too much weight and reported she felt bloated and had rolls of fat
on her stomach. She denied current suicidal thoughts and requested leave. The
Psychiatric Registrar, Dr Dominic, who had been present when Dr Ojo had last
assessed Carole, indicated he was happy for Carole to have escorted leave to the
kiosk in a wheelchair but would need to discuss with the consultant and her
husband if they were happy for her to have leave outside the hospital. A note
was made at the end of this medical review that Carole could have escorted leave
to the kiosk for 30 minutes twice a day, if supervised, and preferably in a
84. A later note was made that Carole had some escorted ground access with
staff, which presumably was in relation to visits to the kiosk.90 There was
evidence given that the kiosk is at the opposite end of the hospital to Mimidi
Park, and at least 100 – 150 metres walk down a covered, enclosed walkway, with
various exit points along the walkway.91
DECISION TO GRANT ESCORTED LEAVE ON 3 OCTOBER 2017
85. As noted above, Dr Ojo went on annual leave on 21 September 2017. He did not
grant Carole escorted leave before he commenced his leave, but Carole was still
at an early stage in her treatment then, and he had just ordered that she have
the nasogatric tube inserted. Dr Ojo had, however, approved Carole going to
group sessions on the open ward. Dr Ojo indicated in his statement that escorted
leave within the hospital grounds is a usual part of the treatment plan, as part
of a graduated recovery plan. After successful escorted leave, the plan usually
then involves periods of unescorted leave within the hospital grounds, followed
by leave at home before discharge. In determining whether a patient would be
granted leave, either within or outside the hospital, Dr Ojo explained that a
mental state examination should be undertaken by the treating team to consider
the risk, physical state of the patient, vital signs and their mental state,
including any suicidal thoughts and their willingness to stay in hospital.
86. Dr Ojo gave evidence that he had not granted any leave for Carole to
participate in escorted ground access before he went on leave himself, because
of her medical state. She was still quite frail and medically unstable at that
time, and had been admitted overnight to the general ward for a medical incident
shortly before that time.
87. Dr Biju Thomas was working as a Consultant Psychiatrist in the inpatient
unit at Rockingham Hospital in October 2017 and, while Dr Ojo was on leave, Dr
Thomas was covering Carole’s care for Dr Ojo. As he was only filling in as
Carole’s treating psychiatrist, Dr Thomas had limited input into Carole’s care
and had limited knowledge of her as a patient prior to her absconding on 3
October 2017. Dr Thomas recalled he saw Carole personally only twice in that
period, on 26 and 27 September 2017. The first time was to reassure and support
her and answer some questions about her care, and the second time was in order
to inform Carole that she would continue to be detained under the Mental Health
Act for a further period. Dr Thomas gave evidence this was done as Carole was
still quite concerned about weight gain and did not appear to understand the
gravity of her eating disorder at that stage.94 Dr Thomas had also seen Carole
on 7 September 2017, when she first came in to hospital, at which time she was
actively suicidal, but Dr Ojo had then taken over her care.
88. There is a note in the medical record that Carole was not able to be granted
leave on 28 September 2017 as she was “too unstable.”96 Dr Thomas gave evidence
that this was a reference to Carole’s physical state being too medically
unstable, rather than her mental state. He noted that her physical state had
been quite changeable, with fluctuations in her blood pressure and pulse, which
were a cause for concern at that time.
89. Dr Thomas did not recall signing anything giving Carole permission to leave
the ward,98 and there is nothing to indicate that he did so. However, he
acknowledged it was likely a more junior medical officer did discuss with him
the granting of leave to visit the kiosk on 2 October 2017, and he would have
90. Dr Thomas indicated in his statement if he had been asked, he would also
have approved Carole going on escorted leave on 3 October 2017, although it does
not seem that he was consulted. Dr Thomas noted that Carole had gone to the
hospital kiosk on 2 October 2017 without incident, which would have provided
some reassurance about extending the scope of the leave. Carole also had the
additional care in terms of her one-to-one special nursing assistant and had
given no indication at that stage to hospital staff that she would try to
abscond, so Dr Thomas felt he would not have had any issues with granting Carole
escorted ground leave. Dr Thomas also indicated that, given the escorted leave
to the kiosk had gone well on 2 October 2017, he would not have expected another
formal mental state examination to be undertaken on 3 October 2017 before that
decision was made.
91. Dr Ojo returned from annual leave on 3 October 2017. He was not working at
Rockingham Hospital that day, but was on duty at Peel Health Campus. Dr Ojo
indicated it was his expectation he would have been consulted about Carole being
granted leave, as he was on duty. However, he was not consulted regarding Carole
having escorted ground access leave that day.
92. Like Dr Thomas, Dr Ojo gave evidence that it was likely if he had been
asked, he would have granted Carole escorted ground leave. He qualified his
opinion as depending on the outcome of the mental state examination and risk
assessment he would have expected to occur, but, based upon his review of the
materials available, he believes he probably would have granted Carole escorted
leave at the time. Dr Ojo explained that he would have done so as Carole was
feeling too contained within the hospital and she had denied any suicidal
thoughts or risk to herself at the time, so there was a need to try to work with
her and reward her cooperation with her treatment and respect her autonomy by
giving her a little more freedom. Dr Ojo also indicated that, based upon what
was known about her physical health at that time, he would not have expected
that she would be able to abscond in the way that she did.102 His earlier
concerns about her frailty would have been alleviated as she had been receiving
sustenance from the nasogastric tube. Also, knowing that she would be supervised
would have reassured him that she was improving and in safe hands.
93. Both Dr Thomas and Dr Ojo accepted that in hindsight, with the additional
information we know now about what Carole was telling other patients and her
husband, the risk of her absconding was clearly higher than it appeared at the
time. However, the assessment of risk relies upon the subjective reports of the
patient, and the practitioners will usually take a patient’s statements about
thoughts of suicide at face value unless there is other objective evidence to
contradict them. Without anyone informing the staff that a patient was telling
other people of suicidal thoughts, it was unlikely they would be aware of this
information. Dr Ojo also indicated that it would not be usual practice to
consult a family member about the decision to grant escorted ground access, only
consultation with the patient.
94. The last entry in the Integrated Progress Notes in relation to escorted
leave indicates Carole had been asking if she could have leave and the team (the
Psychiatric Registrar Dr Dominic, the RMO Dr Dikstaal and Registered Nurse Bibin
Kurian) were happy for her to have escorted leave to the kiosk in a wheelchair
but would check with the Consultant about any other leave. It was noted that
“leave outside of hospital will need to discuss with Consultant and if partner
95. As noted above, Mr Lampard had been present when the topic of escorted leave
had been raised the previous day, and he had been supportive in a general sense
about having leave. A nursing note had been made at 8.00 pm on 1 October 2017
that Mr Lampard had said he could take Carole out if leave was granted.106 There
is, however, nothing to indicate that Mr Lampard was spoken to again after the
medical team meeting on 2 October 2017. Mr Lampard confirmed in his evidence at
the inquest that he was not asked or told about Carole having permission to have
escorted ground access, but he said he assumed that he would have trusted their
judgment and thought that they would do their jobs and keep her safe, so he
would not have objected if he had been informed. However, he also indicated
that, if asked, he would likely have shared the information about their
conversation in the courtyard that she felt she could jump the fence and her
ongoing discussion about suicide, which may have influenced a risk assessment.
96. Despite the reference to a discussion with a Consultant, there is also no
note to indicate this took place, and as noted above, neither Consultant
involved in Carole’s care around that time recalled being spoken to about the
97. It is also unclear whether anyone on the treating team was aware that a few
months earlier, Carole had run away from the hospital while being pushed in a
wheelchair on an escorted walk in the hospital grounds.
ABSCONDMENT FROM HOSPITAL
98. Carole remained an involuntary patient on the morning of 3 October 2017,
although she was now managed in the open ward. The involuntary inpatient
treatment order was not due to expire until 27 November 2017, although it was
always open to be reviewed.
99. Carole’s last weight recorded on the morning of 3 October 2017 was 45.16 kg,
showing the nasogastric tube was having an effect. She had actually reached the
goal weight originally set, but after adding in the 1kg weight of the cast, she
had just under 1 kg more to go.
100. Carole was seen by a doctor at 6.30 am due to an acute change in the colour
and temperature of her hand on the arm with the plaster cast, raising concerns.
The plan was made to elevate her arm where possible, and it was intended that
she would be reviewed for a possible cast change later in the morning.
101. Carole attended the daily community meeting that morning, which was
generally run by the Peer Recovery Worker and Occupational Therapy Assistant and
attended by adult patients. The meeting provided patients with general
information, an opportunity to ask questions and also to give feedback to staff.
In addition, scheduled ward activities would be explained, with the patients
then given an opportunity to nominate the activities they wished to participate
102. It was explained at the inquest that the combined therapy program is
designed to provide a variety of creative, therapeutic and interesting groups
that are educational and provide solace from the medical side of the ward. They
are intended to help the patients “to have hope, to have choices, to … connect
with people”110 and hopefully help them to not feel “so boxed in”111 on the
103. Patients wanting to participate in group therapy walks required permission
to attend. Therefore, if a patient nominated their interest in attending the
group walk, the Peer Recovery Worker and Occupational Therapy Assistant would
discuss the patient’s request to attend the walk with the patient’s allocated
nurse. It was then the allocated nurse’s responsibility to seek permission from
the patient’s treating medical staff. Once permission was granted, the patient’s
name was written on the Therapy Whiteboard.
104. During the community meeting, Carole expressed interest in attending that
day’s scheduled morning group walk, which was due to take place from 10.00 am to
10.30 am in the hospital grounds. The route would usually involve walking on the
internal road and through the hospital carparks within the hospital grounds.
105. Ms Deepika (Dee) Hettihewa was allocated as the Occupational Therapy
Assistant to the Adult Ward that day as another staff member was absent due to
illness. Ms Hettihewa had to cover both that position, and her usual role on the
Older Adult Ward, as a result. As Ms Hettihewa usually worked on the Older Adult
Ward, she had not much contact with Carole before that day.
106. Ms Hettihewa recalled that she thought it was a positive sign that Carole
had expressed an interest in attending the group walk, and she spoke to Carole’s
allocated nurse, a male nurse whose identity she could not recall, to get
permission. Ms Hettihewa recalled the nurse was unsure if Carole would be
permitted to attend the walk, and told her he would follow up with Carole’s
doctor. A short time later, the nurse confirmed that Carole was permitted to
attend walk with a one-to-one special nurse in attendance. Carole was already
accompanied on the ward by a one-to-one special nurse, who was an agency
assistant in nursing. The one-to-one special nurse would be in addition to the
two staff who would always be present on the walk. Ms Jennifer Stockdale, the
Senior Occupational Therapist on the ward at the time, had not spoken to the
nursing staff or medical staff herself about Carole’s approval, as she was not
going on the walk, but she was informed of the approval by Ms Hettihewa.
107. Carole went on the escorted group walk in a wheelchair, which was pushed by
the agency assistant in nursing allocated as the one-to-one nurse special for
Carole, Ms Rupinder Kaur. Ms Hettihewa was the Occupational Therapy Assistant on
the walk and Ms Claire Willans was the Peer Recovery Worker on the walk. Four
other patients also went on the walk. Carole was in a wheelchair as she had a
nasogastric tube inserted at the time and was not meant to be engaging in
activities where she would exert energy. Ms Willans recalls Carole was seated in
the wheelchair, with a blanket on her lap and attached to a drip. She appeared
fairly well-tucked into the wheelchair.
108. The walk began at about 10.00 am. They had been walking for approximately
10 minutes and reached the front of the hospital, adjacent to Elanora Drive,
when they stopped to allow a car to pass on the internal road. The group split
into two at that time, and moved to different sides of the internal road while
the car passed. Carole, Mr Kaur, Ms Willans and another patient were together on
one side of the road. When the wheelchair stopped, Carole suddenly stood up from
her wheelchair, threw her blanket to the ground, pulled the drip from her body
and began running away from the group. She ran at a fast pace across the road
and along a path towards Ennis Avenue. The staff were all taken very much by
surprise by Carole’s actions as she had given no intention she was going to run
away until that moment. Ms Willans indicated in her statement she was
particularly surprised as Carole had looked weak and frail in the wheelchair. It
appeared to Ms Willans that Carole may have planned her escape attempt as she
chose the quickest and shortest route that would enable her to leave the
hospital and cross the road fairly easily.
109. Ms Hettihewa called out to Carole to stop several times, but she continued
running. Ms Willans gave chase, and noted Carole did not appear to have any
difficulty running, although Ms Hettihewa did see her stop briefly against a
tree as if to regain her balance and had thought she appeared a little weak. As
Ms Willans ran after her, she called out to Carole and saw Carole look back once
or twice as she ran ahead of her, but she did not stop. Both Ms Willans and Ms
Hettihewa saw Carole drop something in a bin as she ran past it. Ms Willans was
not expecting Carole to make it very far, given her apparent frailty, and was
expecting to catch up with her quickly. However, Carole continued to run at a
fast pace and Ms Willans eventually had to stop running as she had a heart
condition that does not permit her to do cardio exercise for more than a few
minutes. Ms Willans did continue to follow Carole, at a walking pace, but Carole
continued to increase the distance between them and was soon out of Ms Willans’
sight. The last Ms Willans saw of her was as Carole ran towards the park on
Elanora Drive and turned the corner. Ms Willans then returned to the hospital.
110. Staff are required to take the work mobile phone with them when going on
group walks and Ms Hettihewa had used the work mobile to call the Mimidi Park
reception (the number being saved into the phone) to ask to be put through to
the Adult Ward. Unfortunately, the person who took the call said she was unable
to put the call through as she was busy in the Older Adult Ward, so she asked Ms
Hettihewa to call the Adult Ward direct and put the phone down. The Adult Ward
direct number was not saved in the phone, so Ms Hettihewa tried calling back
reception a couple of times, but the number was engaged. As they were outside
the main entrance of Rockingham Hospital, Ms Hettihewa walked into main
reception area with the other four patients and the agency nurse to ask for the
number to call the Adult Ward directly. She was provided with the correct number
and rang and informed a nurse on the Adult Ward. The nurse told Ms Hettihewa to
return back to the ward with the other patients. Ms Hettihewa stated that it did
not occur to her at the time to call and inform security. Instead, she
concentrated on getting the other patients back to the ward safely.
111. An entry in the Integrated Progress Notes for Carole indicates the first
notification to the ward came from main reception, at which time the staff on
the ward were informed of Carole’s absconding on the walk. Hospital security
were then informed at 10.15 am, and security staff conducted a search of the
hospital grounds. At 10.30 am the Nurse Unit Manger was informed and a call was
placed to Carole’s husband at 10.34 am, with a message left on his voicemail. An
attempt was also made to call Carole on her mobile phone, but it went straight
to voicemail, so a message was also left for her. At 10.40 am Carole’s
psychiatrist, Dr Ojo, and the psychiatric registrar, Dr Dominic, were
112. After returning the other four patients to the ward, Ms Hettihewa spoke to
Ms Stockdale and informed her of the events. Ms Willans returned to the ward and
indicated she had been unable to catch up to Carole
113. The medical notes indicate that an ‘absconder report’ was sent by email
from the hospital to police at 11.10 am. This was followed up by a courtesy call
to Rockingham Police at 11.20 am.
114. The WA Police Incident Report has its first entry at 12.15 pm. Carole was
recorded as a high-risk mental health absconder who had gone missing from the
Mimidi Park Open Ward of Rockingham Hospital. She had last been seen at 10.10 am
and was considered to be at high risk of suicide or self-harm as she had
previously attempted suicide by gassing.123 The task was put on the system as a
Priority 3 Job Code 49 (349) High Risk Mental Health Absconder.124 This priority
indicates that police attendance is required but it is not considered a
life-threatening situation or that there is imminent threat to life. It was
generally expected that police would attend within one hour.
115. In accordance with tasking protocols in 2017, it was allocated to the South
Metropolitan District Control Centre, who then contacted the hospital and
confirmed a Form 6A of the Mental Health Act was in force in relation to her
until 27 November 2017, meaning she was an involuntary patient who could be
apprehended by police and returned to the hospital.
116. The Incident Report was updated at 12.30 pm to indicate that someone had
spoken to Mr Lampard, who suggested that Carole might hitchhike home as she had
done so before.
117. Police officers went to Carole’s home in Coodanup at 12.57 pm and found
nothing to suggest that someone had been there recently. Some contractors had
been out the front of the house for the last hour and they had not seen anyone
coming or going to the house in that time.
THE SALVATION ARMY
118. Tamara Pilgrim, who worked at the Salvation Army, reported that at around
12.30 pm on 3 October 2017 Carole was brought into the Rockingham Salvation Army
Office in Coolongup by a member of the public who had found her near the beach.
They had received a phone call from a member of the public shortly before,
indicating they were bringing her in.129 When she arrived, Carole was soaking
wet. The Salvation Army staff formed the impression that Carole had deliberately
walked into the water and she was possibly suicidal.130 Ms Pilgrim recognised
Carole, as she had previously volunteered there, so she went through the
volunteer files to find her details. There were, however, no emergency contact
details on the file.
119. They could see Carole was wet and shaking with cold, so they provided her
with a shower, dry clothes and coffee. Carole had a hospital band on her wrist,
which was cut off at her request, and she had a plaster cast on her arm, so one
of the staff members telephoned the hospital to let them know that Carole was
there.132 After she had showered, one of the volunteers, Sharon Tregear, sat
with Carole and asked if she wanted to talk about what had happened. It was
clear she didn’t want to, so they engaged in small talk for a while. Ms Tregear
then asked her again what had happened. After Carole confirmed the conversation
would remain confidential, Carole told her she had gone down to the beach and
walked into the water, but she found it too cold so she came back out. A
gentleman offered her help and got her a towel and she then asked him to bring
her to the Salvation Army. Ms Traeger gave evidence she formed the impression
from this conversation that Carole had attempted to commit suicide, although
Carole did not expressly say that was what she had intended.
120. The Rockingham Hospital records indicate that hospital staff received a
telephone call from the Salvation Army (unclear at what time) to tell them
Carole was there and that a member of the public had “found her walking in the
ocean.”134 The Salvation Army had got her information from Carole’s hospital
band.135 Ms Sue French from the Salvation Army made the call and was told that
the hospital staff would contact the police and pass on the information.136 The
ward clerk Ben contacted the police and was updated that police were en route to
collect her. The note also indicated Mr Lampard was telephoned at 2.05 pm and
121. Ms Tregear recalled that another staff member told her they had phoned the
hospital and police, and the police would be there within the hour. Carole was
seated nearby at a table in the café area, but out of earshot, during this
122. Ms Tregear took Carole into the op shop area to get her some better
clothes. The op shop is adjacent to the main building. While there, Ms Tregear
asked Carole if she wanted to call her husband. Carole told Ms Tregear they were
not together anymore and declined Ms Tregear’s request to call him. Carole was
given some more coffee and a warm meal, of which she only ate a couple of
123. Carole started asking Ms Tregear when her wet clothes would be dry, as she
wanted to leave. Ms Tregear told her the clothes were in a machine with a timer,
so they couldn’t interrupt the cycle. She was aware the police were coming and
was trying to keep Carole there until they arrived. Ms Tregear believes Carole
could tell she was trying to stall her.
124. Ms Tregear asked another volunteer, Beverley Bennett to sit with Carole and
try to keep her there. Ms Bennett recalled she sat with Carole for 30 to 40
minutes. Ms Bennett recalled that there was not much conversation between them,
but she appeared rational and was making sense when they did speak.141 At some
stage, Carole asked her if the police had been called. Ms Bennett tried to
deflect her question, but Carole was immediately suspicious and became restless.
Shortly after, Carole walked out the door of the Salvation Army. Ms Bennett
estimated it was around 2.20 to 2.30 pm. Ms Bennett also remembered Carole was
“very, very thin”142 and “very determined,”143 not to let anyone be in control
of her now that she had got out of the hospital.
125. After Carole left, Ms Tregear and Ms Bennett both got in their cars and
separately drove around trying to look for her. Ms Tregear drove to the coast,
as she was worried that Carole might head to the water again, but she did not
see her. Ms Bennett followed Carole to the Waikiki shopping village and last saw
Carole heading down Read Street, towards the roundabout at Safety Bay Road. Ms
Bennett recalled Carole was walking quickly and with purpose.145 She did not
think Carole had seen her. Ms Bennett told Ms Tregear, who came to that location
and also saw Carole there. She telephoned Ms Pilgrim to advise her of whether
they had last seen Carole, so she could update the police. Ms Tregear and Ms
Bennett then went home.
126. Ms Pilgrim recalled that one of the volunteers told her that Carole had
said that she might head home, and when she was asked whether she would be able
to get inside, she said a key was placed outside. This supported the idea she
might eventually go home, like she usually did.147
127. Evidence indicates Carole had arrived at the Salvation Army at 12.47 pm and
left at approximately 2.24 pm (based on CCTV footage), so more than an hour and
half later.148 It is obviously very unfortunate that the police did not attend
the Salvation Army in the one and a half hour period when Carole was there. The
Salvation Army staff and volunteers did their very best to try to keep Carole
warm, safe and well, but they were not in a position to stop her from leaving
when she chose to go. Two of the volunteers did try to follow her for a period,
in the hope that police would arrive soon and they could point them in the right
direction, but regrettably the police were still unavailable. By the time the
police did arrive in the area, Carole was long gone.149 One of the Salvation
Army volunteers commented at the inquest that she did still wonder why the
police never attended on the day.
128. The Rockingham Hospital medical records indicate police had spoken to a
hospital staff member at 12.25 pm and indicated the police would go to Carole’s
home address. A later entry made in the notes at 3.00 pm, but apparently
recording slightly earlier events, indicates the Ward Clerk received a phone
call from the Salvation Army indicating that Carole was with them. The Ward
Clerk then contacted police and updated them with this information. They were
told police were on their way to collect Carole and Mr Lampard was notified of
this information at 2.05 pm. A further call was then received from the Salvation
Army at 2.35 pm to inform them that Carole had left. Another phone call was made
by the Ward Clerk to police to update them on the direction Carole had left and
another call was made to update Mr Lampard at 2.45 pm.
129. Police records indicate that the WA Police were aware that Carole had
absconded from Mimidi Park at 12.15 pm on 3 October 2017. At 12.30 pm a
dispatcher spoke to someone at the hospital to get more details and it was
entered that Carole was considered high risk, given previous comments she had
made, and Mr Lampard had suggested Carole was likely to make her way home as she
had previously hitchhiked home in a similar situation. Police officers were
tasked to go to Carole’s home, where they found no sign that anyone had been
there recently and contractors who had been working nearby confirmed that they
had seen no one arriving at, or leaving, the address.
130. The WA Police Incident Report records information that Carole might be at
the Salvation Army in Read Street, Rockingham, at 2.13 pm. This was after a
linked job was created at 2.05 pm and a search was done for the Salvation Army’s
details. Unsuccessful attempts were made by the police to call the Salvation
Army as it went to an answering machine. A general call was then put out at 2.45
pm to any cars available in the area, but there were no takers as all cars were
busy on other tasks.
131. The next call at 2.54 pm indicated that Carole had left the Salvation Army
office and had last been seen heading south on Read Street in Rockingham about
half an hour before. She was now wearing different clothing to the earlier
report, having changed clothes at the Salvation Army. A note in the police
Incident Report suggests Carole had told a Salvation Army member that she was
intending to hitch a lift to Mandurah. There were still no vehicles available,
and this remained the case for the next few hours. No attempts appear to have
been made to actively look for Carole again until officers went to her home
again at 2.13 am on 4 October 2017, again finding the home empty and with no
sign of anyone having been there recently.
132. Mr Lampard was notified by hospital staff by telephone sometime after
midday that Carole had run away. He had missed the first call, but answered the
second call at around 12.40 pm on his mobile. He was advised that Carole had
absconded from the hospital and was asked if he had heard from her. He was not
at home at the time and hadn’t heard from her. He had not seen or spoken to her
since his visit on the Sunday, two days before. Mr Lampard then received another
call to say that Carole was at the Salvation Army and the police were out
looking for her. He assumed she would be collected and readmitted to hospital.
However, he was then notified that the police had missed her at the Salvation
Army and she was still missing.
133. The next day, being 4 October 2017, Mr Lampard went to the Salvation Army
and spoke to Ms Pilgrim about what had happened. Ms Pilgrim told him that Carole
had mentioned to one of the volunteers that she might head home.156 He collected
Carole’s clothes before leaving. Mr Lampard then attended the Mandurah Police
Station to provide information to police to assist them in their missing person
search. He signed a detailed statement on 10 October 2017. On 16 October 2017,
Mr Lampard provided the police with more information about Carole’s background
and the people and places Carole might visit.157 Mr Lampard conducted his own
searches for Carole with the assistance of friends, without success.
WHY DIDN’T POLICE ATTEND?
134. A question that arose during the inquest was why the WA Police did not
attend the Salvation Army earlier, while Carole was still present?
Superintendent Martin Cope attended the inquest to provide evidence on this
point. Superintendent Cope explained that he had reviewed the relevant records
and identified that there had been a failed attempt by the district control
centre officers to call the Salvation Army on the day, as the phone had been
switched to an answering machine. There were then attempts to send a police car
to the Salvation Army, to make further enquiries, but unfortunately no police
cars were available to attend at the time.
135. The attendance was given a priority 3, which required general police
attendance. It was recorded as being related to a high risk mental health
absconder. This was consistent with the policy at the time. The policy has since
changed, and it would now be given a priority 2, which is a higher level of
136. Based on the priority that was allocated at the time, a response time of
one hour was designated, but no police cars became available in that time frame.
This is a great pity, as it seems clear that if a police car had been available
to attend in a reasonable time frame, they would have been able to apprehend
Carole and return her to the hospital. Mr Lampard also expressed his
disappointment at the inquest in relation to the delayed police response to the
report that Carole was at the Salvation Army. He commented that it was “tragic
that for the want of one police car with two police officers, Carole is now
137. I note the police did attend Carole’s house earlier in the day, when it was
thought she might return there, and conducted a thorough investigation in the
days that followed. However, at the most important time, when Carole was
actually known to be in a certain place and able to be apprehended, no police
were available. Unfortunately, that is the reality that we face on a daily
basis, where police must juggle various priorities with limited resources.
However, this provides small comfort to Carole’s family and friends, knowing
that if police had been available, this inquest might never have been needed.
138. It was also apparent from the evidence that the level of risk and concern
in relation to Carole may not adequately have been conveyed to the police, at
least at the time she was with the Salvation Army officers, as the communication
was being done through the hospital. It is unfortunate that the call through by
police to the Salvation Army were not successful, as I believe that a direction
conversation may have provided more relevant information to the police that
could perhaps have prompted greater endeavours to get there quickly. However, as
Superintendent Cope indicated, the lack of a car to task was the problem, so
even knowing that the risk was greater than perhaps initially appreciated, it
may not have resulted in a different outcome.
139. It was indicated at the inquest that the WA Police are considering making
changes to the WA Police Manual and the absconder form at the South Metropolitan
Health Service, to improve communication in similar cases.
LATER POLICE INVESTIGATION
140. The initial phase of the police investigation was an attempt to locate
Carole and return her to hospital, as noted above.
141. Mr Lampard had also gone to his home a few times on 3 October 2017, and
again on the morning of 4 October 2017, and found no sign that Carole had been
there.164 Over the following days, Mr Lampard also checked other places where
Carole might have gone, without any luck. He told the police on 6 October 2017
that she had not accessed a credit card and cash he had left out for her, in
case she returned home, and she had not used her Facebook or email account.
142. On 6 October 2017 the carriage of the investigation was transferred to
Rockingham Police Station and appears to have been upgraded to a full missing
person search, with a Land Search and Rescue Operation (LandSAR) initiated.166
Police officers spoke to the Salvation Army staff again on 7 October 2017 and
searched the Waikiki Shopping Village and spoke to people there. No new
sightings of Carole were confirmed. The bodies of water in the area were also
inspected for any sign Carole might have been there.
143. Tracker dogs sourced by Mr Lampard had repeatedly provided an indication
that Carole had been in the Mandurah foreshore area, with particular attention
given to a jetty opposite a café. Police officers from the Police Diving Squad
searched the water at the Mandurah Estuary in the area of the jetty on 13
October 2017. No items were located during the dive that were felt to be
relevant to Carole’s disappearance.
144. Police officers also visited various homes where Carole was known to have
house sat in the past, with no sightings of her. Any available CCTV footage in
the Mandurah CBD was also reviewed.
145. The police investigation explored the possibility that there might have
been some criminality in relation to Carole’s disappearance, but no evidence was
identified to support such a conclusion.
146. Police made enquiries with the farm organisation, WWOOF Australia, which Mr
Lampard and Carole had been involved with before when looking for accommodation
and food in return for work, but they had no record of Carole contacting them
147. Mr Lampard located Carole’s diary at home in a cupboard. The diary had
entries related to her drinking and food intake, as well as repeated daily
entries about wanting to die quickly and peacefully written from 16 August 2017
until 3 September 2017. He also found a notebook, which contained reference to
dying. Mr Lampard recalled she often had the diary and notebook with her. He
provided it to the police around 18 October 2017.
148. On 26 October 2017 local police in Shark Bay were asked to go to Nanga Bay
Resort, Shell Beach and other locations in that area to check for any sign of
Carole, and after no sign of her was found, Carole’s ‘Missing Person’ photograph
was put up in these locations, in case she did turn up there later.
149. On 16 November 2017 officers from the Missing Persons Unit confirmed that
there had been no transactions by Carole on her bank account and she had not had
any interaction with Centrelink or Medicare. Immigration checks indicated there
was no record that Carole had left Australia.
150. From the information gathered in the investigation, up to December 2017, it
was apparent to the police that Carole “was a strong-willed individual whom had
the experience and capability to fend for herself and live a spartan existence.
It was clear that Carole would probably not reach out to her husband as she
blamed him for having her committed in the first place and wanted to live a life
without any material constraints.”
151. By mid-December 2017, after 90 days had passed without locating any sign of
Carole and no evidence of criminality, it was determined that Carole met the
criteria for a long-term missing person and ongoing management of the
investigation into her disappearance was allocated to the WA Police Missing
OTHER INFORMATION AND POSSIBLE SIGHTINGS
152. As part of the police investigation, there was extensive media coverage of
Carole’s disappearance. This prompted numerous unconfirmed sightings of Carole.
153. There was a possible sighting of Carole hitchhiking near the Safety Bay off
ramp during the afternoon of 3 October 2017. The person saw a female between
3.00 and 4.00 pm and remembered that she was standing halfway down the on ramp,
in a dangerous position. He recalled she appeared very thin and seemed to be
154. Another motorist was driving in that same area at a time between 3.45 and
4.00 pm and she also noticed a small, frail woman hitchhiking down the side of
the off ramp.
155. Information recorded in the police incident summary suggests someone told
the police later that Carole may have said she was going to hitchhike to
Mandurah. She had done so before when she absconded from hospital.180 The two
sightings would appear to be consistent with Carole certainly attempting to
hitchhike out of the area and presumably heading to Mandurah, where she usually
156. Another person thought he may have seen Carole on a train heading from
Perth to Mandurah on 6 October 2017. She was very thin and was carrying a bag
that said ‘property of Salvation Army’.
157. A person who worked at the Peel Community Soup Kitchen told a police
officer that they had seen a woman matching Carole’s description at the soup
kitchen on 9 October 2017. The soup kitchen worker remembered the person as
looking quite frail and sick. She ate her soup alone, without speaking to anyone
else, then left.182 A police report indicated several other sources confirmed
this sighting, leading the police to believe Carole was ‘living rough’ in the
Mandurah area and avoiding detection as she did not want to be returned to
hospital. Areas were itinerant and homeless people were known to congregate in
Mandurah, and camping areas, were checked by police, with no sign of Carole.
This sighting was later treated by police as a confirmed sighting of Carole.
158. Mr Lampard spoke to a female manager at the Nanga Bay Resort, where he had
recently stayed with his wife. The manager thought she might have seen Carole.
Mr Lampard provided the information to the police, although he indicated he
accepted it was a long shot. The manager recalled Carole from her previous stay
in June 2017 and after being contacted by Mr Lampard, she told police she
recalled a woman who was similar in appearance to Carole at the resort on 10
October 2017, although she did not have a booking there.185 This would appear to
be inconsistent with other sightings of Carole in Mandurah around that time.
159. Another patient who had been in Mimidi Park at the same time as Carole
signed a statement on 26 October 2017 in which she indicated she had met Carole
for the first time between 8 and 12 September 2017. At that time the patient was
heavily medicated and had little memory of their conversations. However, the
patient was re admitted to Mimidi Park in late September and during this
admission she met and spoke with Carole again, including on 1 October 2017, a
couple of days prior to Carole absconding. The patient had a clear recollection
that Carole was making jokes about running out the front door of the open ward
and asked the patient, who was being discharged the next day, if she would come
and fetch her from the carpark. The patient said she ignored Carole and changed
the subject. However, she did speak to Carole about what she would do if she
were to run away, and she told Carole that on Tuesdays she goes to the Salvation
Army in Waikiki for lunch, which might be relevant considered the events two
days later, as Carole may have hoped to see the patient and get some assistance
160. Carole and the patient also discussed how Carole could easily remove the
nasogastric tube and Carole’s concern that if she ran away her clothes would not
fit her as she had put on weight in hospital. Carole and the patient then
reportedly discussed suicide for quite a while. They were both on the locked
ward due to being suicidal, and the patient said they spoke about the most
efficient way to kill themselves. Carole told the patient at that time that she
wanted to escape so she could kill herself, and the patient believed Carole had
made up her mind about doing this. She told the patient she had detached from
her husband and didn’t want him, or anyone else, to visit her in hospital. She
was frustrated with the hospital and her treatment and denied that she had an
eating disorder, instead indicating that she simply didn’t want to live anymore.
The patient saw Carole briefly the next day and said goodbye before she was
discharged. She told police she had not seen or heard from Carole again after
leaving the hospital.
RECENT POLICE REVIEW
161. A check with Medicare has revealed no Medicare or pharmaceutical claims
were made in relation to Carole after 3 October 2017. Other proof of life checks
with Centrelink and the banks has found no evidence of Carole accessing services
since 3 October 2017. Immigration records indicate Carole was a New Zealand
citizen and was onshore in Australia as the lawful holder of a Special Category
Visa at the time of her disappearance. There is no evidence to suggest she has
left the country.
162. At the time of the inquest, the police investigation had reached the
conclusion that it was unlikely that Carole was still alive. The early police
investigation ruled out any possible criminality in Carole’s disappearance and
that position has not changed. Therefore, her death occurred by some manner
other than homicide.
VIEWS OF FAMILY AND FRIENDS
163. Carole’s husband, Chris Lampard, and sister, Elizabeth Phillips, both
provided additional information for the inquest.
164. Ms Phillips emphasised the distress and upset that Carole’s disappearance
has caused to all of her family, in particular her frail and elderly parents. As
a family, they emphasised that Carole was a much loved member of a large family.
They knew, as a family, that she had an eating disorder that had adversely
affected her mental health and overall well-being, but were still not expecting
this tragic outcome.
165. Ms Phillips indicated her family’s belief that a number of factors
contributed to the final decline in Carole’s mental state, including a milestone
50th birthday, the sudden death of her brother and her mother’s recent stroke.
These events caused Carole considerable upset and worry, particular the family
events occurring while she was so far away. Ms Phillips and other family members
kept in regular contact with Carole and her husband and they had actually felt
relief when Mr Lampard told them that Carole had been made an involuntary
patient, as they hoped it would provide an opportunity for Carole to receive the
care and support she clearly needed in a safe environment.
166. It was, therefore, with “absolute disbelief”192 that they processed the
news from Mr Lampard that Carole had gone missing from the hospital. They hoped
and prayed that Carole would be found safe and well, but as time has gone on,
that feeling of hope has disappeared and turned to sadness with the realisation
that Carole has died. Carole’s parents have never got over this loss and they
167. Ms Phillips indicated that she and her extended family have read all of the
materials relevant to the inquest and they express the view that there were a
series of unfortunate failings that led to Carole’s disappearance, including a
health facility not able to deal with people with an eating disorder, and
individual and systemic failures in terms of protocols and approvals, as well as
a failure in risk assessments.194 They have, however, expressed their gratitude
to Carole’s husband Chris, who did everything possible to get Carole help, the
Salvation Army staff who offered care and support to Carole in her time of need,
and the WA Police who conducted extensive searches for Carole in the days after
168. Carole’s family expressed the hope that the inquest would indicate that
lessons have been learnt and this will not happen again to another family,
although noting this news will give them little comfort or closure as they will
never know what would have happened if Carole had been kept safe in hospital and
given a chance to recover from her eating disorder.
169. Mr Lampard gave evidence at the inquest to confirm he still holds the
belief that Carole died sometime around the date of her disappearance. Mr
Lampard explained that they had a very close relationship and had spent a great
deal of time together, just the two of them. Mr Lampard noted that he was the
only person Carole was really close to in Australia, so there was no one else
she could really turn to for help. He had witnessed the decline in her mental
health, particularly over the last three years of her life, and knew she was
getting worse even though he had been working really hard to keep Carole happy
and alive. After Carole disappeared in October and did not return home, he knew
in his heart that she was not coming back this time.
170. Although Mr Lampard knew that Carole was angry with him, he still believes
she would have come back to him eventually if she was able to do so. He gave
evidence that he believes if she had survived, he thinks “she would have
recognised that she needed help and eventually come home.” 198 Mr Lampard also
noted that Carole was close to her family, particularly her sister, so even if
she had not contacted him, she would definitely have made contact with her
sister if she was still alive.
171. Mr Lampard gave evidence that the weather was appalling in the first week
that Carole absconded. It was very cold, with lots of rain, and he believes that
she might have died of natural causes given she was so physically frail, or else
she may have finally killed herself, given her previous threats and attempts. Mr
Lampard does not believe that Carole could have survived on her own without some
form of help.
172. In terms of how Carole was able to abscond from the hospital in the first
place, Mr Lampard expressed his opinion that it was a failure on the part of the
hospital staff, given they ought to have been aware that she had previously
absconded from the hospital in the past. He accepted that she could be
calculating and would not have made it clear to them what she was planning, but
he still believed there ought to have been a better assessment of her risk by
the staff based on her history and the fact that she had been successfully
increasing her weight, which would have given her greater energy and ability to
abscond, if she chose to do so.201 Mr Lampard expressed disappointment at the
failure to consult him about the decision to grant her leave, as he believes he
could have suggested he be in attendance, which might have alleviated a lot of
the risk, or at least provided some relevant information for the hospital staff
to assess her risk, given what she had said to him in their last meeting.
173. Rockingham General Hospital initiated its own clinical investigation into
Carole’s escape from the hospital, which was completed on 8 November 2017. There
were two main issues identified in the investigation – the issue of the approval
for leave and the overall care for Carole as a person with an eating disorder.
174. Dr Gordon Shymko is the Mental Health Service Medical Co-Director at the
Peel and Rockingham Kwinana Mental Health Service, which is part of the South
Metropolitan Health Service. The service includes Rockingham Hospital’s Mimidi
Park. Dr Shymko has been working at Rockingham Hospital since 2000, and in his
current role since 2007. Dr Shymko was not personally involved in Carole’s
medical care. Dr Shymko provided evidence about the general policies for mental
health patients at Rockingham Hospital, both at the time of Carole’s admission
in September 2017 and currently.
175. Dr Shymko confirmed that Carole spent time initially on the closed/locked
ward, and then gradually moved to an open ward, with a one to one nursing
special in place throughout her hospitalisation. As the name suggests, there is
more freedom on the open ward, but in Carole’s case, give the nursing special
allocation, she was still quite closely supervised even on the open ward. Dr
Shymko noted it is relatively common for a patient with an eating disorder to
have such a nurse allocated “because often a high degree of supervision is
required to ensure that the person is adhering to the treatment as part of the
eating disorder.”204 The purpose of the supervision, therefore, is to ensure
that she was not exercising too much and complying with her meals and not
interfering with her nasogastric tube.
176. As part of the least-restrictive approach to care, although Carole
continued to be supervised ‘one to one’ by a nurse, she was progressively given
more freedom within the hospital. This included permission to go on supervised
leave to the kiosk. Dr Shymko explained that the ultimate goal for a patient in
hospital is to be discharged from hospital, so the grant of accompanied leave to
the kiosk formed part of the progression towards Carole’s discharge. Dr Shymko
explained that how Carole behaved on this escorted leave would assist the
medical staff to gauge her stability and recovery, and her ability to manage
greater freedoms leading up towards discharge.
177. Although Carole would remain on the hospital grounds at all times, a visit
to the kiosk was still considered to be a grant of a leave of absence, as she
was an involuntary patient leaving the Mimidi Park ward.207 There were two
policies in place regarding patient leave for a mental health patient when
Carole absconded on 3 October 2017. One was a corporate policy for the
Rockingham Peel Group and the other was a clinical policy for the South
Metropolitan Health Service. The Rockingham Peel Group policy required that
involuntary patients were only to be granted a leave of absence by a consultant
psychiatrist, which is consistent with the legislative requirements of the
Mental Health Act.
178. There was some debate during, and after, the inquest, as to whether this
requirement meant that for Carole to be granted escorted leave to visit the
kiosk, it required the approval of a consultant psychiatrist. The same question
was raised in relation to the escorted walk in the hospital grounds.
179. The evidence indicates a psychiatric registrar granted Carole escorted
leave to the kiosk. There is no evidence in the medical notes to indicate that
any medical officer approved the escorted leave in the hospital grounds,
although Ms Hettihewa recalled that an unidentified nurse said they would check
with a medical officer. Certainly, neither grant of leave, either to the kiosk
or into the hospital grounds, was approved by a consultant psychiatrist.
180. While Dr Ojo was away, Dr Biju Thomas was the relief psychiatrist
responsible for Carole’s care and for a decision to grant her leave of absence,
but he was not consulted in relation to Carole being permitted to attend the
kiosk or the group walk on 3 October 2017.210 Dr Ojo had returned from leave
that day, and he also confirmed he was not consulted.
181. Dr Shymko gave evidence that enquiries with the medical staff who were
involved at the relevant time established that they interpreted the requirement
for a consultant to approve a ‘leave of absence’ as applying only to leaving the
hospital and going into the community. Therefore, a registrar approved the
escorted leave to the kiosk.
182. In relation, to the escorted walk in the hospital grounds, enquiries
indicate that the nursing staff appear to have interpreted the approved leave to
the kiosk as approved leave within all of the hospital, including an escorted
walk in the grounds, rather than simply limited to the kiosk.
183. Nurse Kurian, who was involved in discussions about Carole’s leave on 2
October 2017 and often performs the more senior role of Nurse Co-ordinator,
noted that he was always aware that decisions around patient leave were to be
made by the medical staff for all patients. However, it was not a requirement to
record the leave on the Mental Health Authorised Leave Form. Nurse Kurian also
noted that the leave generally granted at the relevant time was either Escorted
Ground Leave, Unescorted Ground Leave, and then day leave and eventually
overnight leave. There does not appear to have been the category of escorted
ground leave only to specific locations (such as the kiosk), so Nurse Kurian
recalls Carole’s approval for escorted ground access to the kiosk but did not
recall any specific reason for indicating only the kiosk. Accordingly, the entry
he made in the system was for “EGA (escorted ground access) with staff on
wheelchair twice day,” with no reference to the kiosk.
184. Nurse Kurian could not recall if he was asked on 3 October 2017 whether
Carole could go on a walk, but indicated it was possible he was asked, and if he
had been he believes he “would have said that Ms Livesey could go on the
walk,”213 based on his understanding that escorted ground leave had been
approved. However, I also note that when Ms Hettihewa spoke to a male nurse, he
indicated that he would check, which was likely to be with the registrar. It is
unclear if that, in fact, occurred, but in any event it is clear it was not
checked with a consultant.
185. There was also a requirement for a progress risk assessment to be conducted
before Carole was allowed out on leave that day, assuming the leave had been
properly approved. Dr Shymko explained that the requirement for a progress risk
assessment was introduced in 2016/2017 as “another layer of assessment of an
individual within the inpatient setting.”215 It is comprised of at least a
partial mental state examination, with the aim to try and determine that
person’s level of risk to themselves or others.216 There is no evidence on the
brief that a progress risk assessment was completed and the hospital’s internal
review report confirmed that the Progress Risk Assessment was not completed
prior to Carole being given escorted ground leave that day. It was noted that
the ward had run out of the relevant file stickers, which may have contributed
to this lapse in process.
186. In terms of a consultant authorising leave, it was noted that a risk
assessment is required, and in part appropriate risk mitigation strategies must
be considered. Dr Shymko indicated that a ‘one-to-one nursing special’ is one of
the major risk mitigation strategies that they use to try and diminish risk, so
it is relevant that this was in place for Carole, even though a consultant had
not made the grant of leave. Dr Ojo also considered that the fact Carole was
being supervised on a nursing special was relevant and minimised the risk.218 It
was also relevant that Carole was seated in a wheelchair and was noted to be
underweight and quite frail and often dizzy, had a nasogastric tube inserted,
had a cast on her leg due to a fractured tibia and a quite heavy cast on her
arm, all of which might have suggested to an observer completing a risk
assessment, that her risk of absconding at that time was low.
187. Dr Shymko also agreed that the policy for granting leave notes that there
are risks involved in both granting, and refusing, leave. Dr Shymko noted that
Carole had been finding the ward environment difficult and there was evidence
her mental state was improving, which in the context of trying to give her some
hope and apply the least restrictive practice, might support a greater grant of
leave. Therefore, based only upon reviewing the notes, Dr Shymko expressed the
opinion that he, as a consultant psychiatrist, would likely have felt it was
appropriate at that time to offer Carole leave off the ward, in a meted manner,
particularly given the length of time she had spent in that restricted setting.
188. In terms of changes arising from these events, a recommendation from the
Clinical Incident Investigation Report was that they use standardised phrases
for leave approval in patients’ records. A process for this was to be developed
189. Dr Shymko also indicated that since the incident involving Carole, hospital
has introduced a new form to be completed for all approvals of a leave of
absence, which must be signed by a consultant psychiatrist, indicating the
consultant agrees with, and has approved, that leave. The leave plan must then
be reviewed every 48 hours.
190. Mr Lampard gave evidence at the inquest that both he and Ms Phillips were
reassured to hear from Dr Shymko’s evidence that changes have been made at
Mimidi Park, following the events surround Carole’s disappearance, which might
keep someone else safe in the future.
191. While the change now confirms that a consultant must approve all leave,
that leaves the question whether there was a requirement under the Mental Health
Act for a consultant psychiatrist to approve Carole’s leave within the hospital
to the kiosk and in the hospital grounds at the relevant time.
192. In submissions filed on behalf of the South Metropolitan Health Service, it
was submitted that “leave of absence” in s105(1) of the Act, is limited to a
place outside the hospital, noting that the words “leave of absence” are
followed by the words “from a hospital”. It is submitted that the hospital
included Rockingham General Hospital and its grounds, and was not limited to the
Mimidi Park In-patient Unit. I note that the Form 6A referred to Rockingham
General Hospital, although only the Mimidi Park Inpatient Unit is an ‘authorised
hospital’ as determined by the Chief Psychiatrist. This might leave open the
issue as to whether leaving Mimidi Park meant that Carole was leaving the
‘hospital’ to go to the kiosk or into the grounds, however, I note the
definition of “hospital” in s 3 of the Act, includes both an authorised
hospital, and a general hospital. Further, I note that information was provided
from the Chief Psychiatrist of Western Australia, as published by the Mental
Health Commission which appears to limit the legal requirements for a ‘leave of
absence’ specifically to overnight leave, although it is suggested that it is
good practice to follow a similar process for day leave.
193. I am persuaded by the information above that Carole did not require the
approval of a consultant psychiatrist to go to the kiosk nor to walk in the
hospital grounds. I note Dr Ojo’s evidence that he would have expected to be
consulted, based on general practice, but that is different to a legal
requirement to do so. Coordinated Eating Disorder Service
194. As part of the broader clinical incident investigation, it was also noted
that there is a lack of specialised eating disorder services Statewide in
Western Australia and there was an absence of a coordinated approach for
patients admitted with eating disorders at the hospital. The review noted Carole
did not have a dietician review until 12 September 2017 and she did not have a
psychology review at all while on the ward.
195. Dr Shymko gave evidence that eating disorders are very complex conditions
and they arguably require tertiary level or highly specialised services. He
confirmed that within Western Australia currently, there is still no service
that manages eating disorders centrally, so individual hospitals are left to
manage eating disorders individually. Dr Shymko indicated that the SAC 1 review
found that Carole’s case demonstrated that at Rockingham Hospital at the time,
there was not a coordinated process between the various services needed to treat
a patient like Carole.
196. Since Carole’s disappearance, the South Metropolitan Health Service
Rockingham Peel Group (South Metro Health Service) has developed a comprehensive
eating disorder policy entitled ‘Multidisciplinary Team Review Process for
Persons Presenting with Eating Disorders (Acute) Guideline’. The policy
recognises and supports the need for the patient and their primary carer to be
engaged in their healthcare and participate in treatment decisions. The policy
refers to an Eating Disorders Review Team, which includes a dietician, as well
as nurses and other allied health staff. The overall governance of the patient
remains with the admitting Consultant, who heads the review team and works with
the other members in a collaborative manner to create a management plan to
establish medical stability and optimise the patient’s care. The team are
required to undertake a review of a new patient within three days of their
197. Carole’s dietician, Ms Wright, had also consulted the WA Eating Disorders
Outreach & Consultation Service (WAEDOCS) on 14 September 2017 regarding
Carole’s treatment plan, noting she had severe malnutrition and significant risk
of refeeding syndrome.
198. WAEDOCS provides a consultation service for clinicians throughout Western
Australia treating patients presenting with an eating disorder. The information
provided on the brief from WAEDOCS explained a little more about the challenges
Carole faced with her care, noting that emerging evidence suggests early
intervention is a key component in improving the prognosis, which was obviously
not possible in Carole’s case given the length of time she had been living with
her eating disorder. Her eating disorder required both physical and mental
health care, but the initial focus had to be on getting Carole medically
stabilised and had gained sufficient weight to allow her brain to recover from
the cognitive effects of starvation, so that she could then benefit from
199. Dr Shymko noted that the new eating disorder guideline implemented by the
South Metro Health Service aligns treatment to the WAEDOCS guidelines, and they
have found that to be quite a successful change. Dr Shymko indicated that the
biggest change is that the dietician in the team, who often leads a lot of the
work with eating disorder patients, is involved pretty much from day one of
admission if the patient is admitted on a weekday, and at least within the first
72 hours of admission if the patient is admitted on a weekend.230 The South
Metro Health Service has also provided training to staff on eating disorder
treatment, by having the WAEDOCS service present and support training
opportunities internally, as well as supporting staff with a particular interest
in the area to engage in individual additional training. Dr Shymko acknowledged
that this does not replace the kind of specialised training ideally required for
such a specialised area of treatment, but they have attempted to provide what
they can locally, with some success.
200. Dr Shymko noted that there were full-time psychologists working at the
hospital and available to treat mental health patients at the time of Carole’s
admission, so he was unsure why she did not see a psychologist. He speculated
that there may have been staffing resource issues at the time, which impacted on
the level of psychology services available, which appears consistent with other
evidence. However, Dr Shymko indicated psychology services should certainly be
available currently as part of the multidisciplinary approach.232 The SAC 1
investigation also identified that there was no specialist eating disorder
psychology services for inpatients at the hospital, so the psychology services
are more general in nature, without the benefit of the specialised training.
201. Mr Lampard expressed his own disappointment at the poor level of care that
was available for Carole to treat her eating disorder in the public health
system. He did not feel that the quality of the food offered was designed to
entice her to eat, and noted that she was given no access to psychological
treatment while an inpatient, so she received no treatment for her underlying
issues during her stay. That was why he was determined to move her into the
private health system, where she could receive specialised treatment.
202. In submissions filed on behalf of the South Metropolitan Health Service,
further information was provided as to the current eating disorder services
available in Western Australia, both in the public and private health systems.
The information was provided by the Mental Health Commission and is helpfully
summarised in the submissions.
203. I am informed that as part of its 2021 election commitment, and subject to
the State Government budget process, the Western Australian State Government has
committed $31.6 million to the expansion of specialist eating disorder services
in Western Australia. The Mental Health Commission is leading a working group,
which involves key clinical and health service provider representatives, to
develop a ‘model of care’ for these proposed services. New services will
integrate with existing services, and in particular address gaps in the
treatment of patients with an eating disorder aged 16 years and over, such as
Carole. The services will include community-based services, with a focus on
early identification intervention and prevention programs, and intensive day
programs. I am informed that it is anticipated that the services will commence
from July 2022.
204. In addition, the Federal Government has recently released, for the first
time, the Australian Eating Disorder Research and Translation Strategy 2021 –
2031. The 10- year strategy is designed to guide critical research in this
complex area and transform how we treat and care for the nearly one million
Australians who suffer from eating disorders. It is intended that the Strategy
will provide a clear national approach to ensuring best-practice, early
intervention and treatment now and in the future. The 2021-22 Federal Budget has
provided $26.9 million to fund the Strategy, including $13 million to establish
a National Eating Disorder Research Centre.
205. Noting that there are significant changes proposed for the treatment of
adult patients with eating disorders in this State and nationally, in addition
to the positive changes already implemented at Rockingham Hospital as a result
of Carole’s case, I do not propose to make any recommendations in relation to
this issue. I have no doubt that Mr Lampard and Ms Phillips will take some
comfort in the fact that there are likely to be much better services available
to other patients like Carole in the future, with lessons having been learnt
from her case as well as others.
IS CAROLE LIVESEY DECEASED?
206. Carole had struggled with her weight and body image for many years but she
appears to have had no previous history of overt self-harming behaviour or
suicide attempts until she began to voice suicidal thoughts in early 2017. As
her mental state deteriorated, she made repeated suicide attempts from May 2017,
by various means, but predominantly by attempted drowning. She was admitted to
hospital on a number of occasions for treatment to manage her low weight and
207. By early October 2017 there had been noticeable improvement in her weight,
but Carole’s mental health had not improved. She had spoken to another patient
of wanting to escape the hospital in order to commit suicide not long before she
disappeared. Carole absconded while on an escorted walk in the hospital grounds
and was found soaking wet about an hour later, suggesting she may have attempted
suicide again by drowning. She was given support and care by Salvation Army
workers, before she left the store and disappeared. She has never been seen
208. I indicated at the conclusion of the inquest that I am satisfied that
Carole has died. Based upon all of the evidence before me, I am satisfied beyond
reasonable doubt that Carole Livesey died around the time of her disappearance.
She had no money, credit cards or any identification with her when she
absconded, so she had no way of supporting herself for any length of time
without assistance. She has not been in contact with any family member, or any
government agency, since she was last seen at the Salvation Army. Given her
history of prior self-harm and suicide attempts, and the known deterioration in
her mental state around the time of her disappearance, with active suicidal
ideation, her death was likely as a result of suicide. There is some evidence
suggesting she may have already entered the water once, just before she
disappeared, and possibly did so again. This is in the context of Carole having
a history of failed suicide attempts by drowning.
209. Although suicide is the most likely manner by which Carole met her death,
there is insufficient evidence for me to be able to be satisfied to the
requisite standard of a cause or manner of death, as without knowing exactly how
she died, accident and natural causes cannot be excluded as possibilities.
Noting her frail physical state and the poor environmental conditions, I can’t
exclude natural causes or even an accidental manner of death. The cause of death
must, therefore, remain unascertained and the manner of death is open.
COMMENTS ON TREATMENT, SUPERVISION AND CARE
210. Having found that Carole is deceased, it is necessary for me to consider
the quality of her treatment, supervision and care prior to her death, given she
was an involuntary patient at the time she absconded and disappeared.
211. It is important to recognise that the Mental Health Act requires that all
mental health care provided under the Act is done in the least restrictive
manner, including within the inpatient setting. When a patient is involuntary,
they no longer have a choice as to whether or not they wish to leave the mental
health service, but they must still be treated in the least restrictive manner
possible, based on their treatment needs. The general aim is to ensure that
patients are receiving appropriate care and advancing towards discharge and
community management wherever possible.
212. I note that the nursing note entry made on 1 October 2017 indicated that
Carole had requested a one on one talk with a registered nurse and had
“basically stated that she was becoming despondent, there is nothing to do.” She
had no interest in occupational therapy groups, no interest in socialising with
her peers and, although she enjoyed reading, she had become bored with it. It is
clear that her zest for life had faded and she was becoming frustrated by her
ongoing containment in an environment that did not provide her with intellectual
stimulation. She indicated in this conversation that she wanted to go out of the
ward for a break and a different scene. A note made later that night indicated
that, following a visit from her husband, Carole was still asking to go out of
the unit and guaranteed her safety, indicating she had no suicidal ideation at
213. Carole was reviewed the next day by the treating team of the registrar,
registered medical officer and a registered nurse, but not the consultant.
During the conversation she repeated her request for leave outside the unit,
which is when the option of escorted leave to the kiosk was discussed. It was
indicated in the notes that this would need to be discussed with the consultant,
and I am satisfied it is likely this was done via a discussion with Dr Thomas,
as he conceded this was likely to have taken place. There is nothing to suggest
any concerns were raised about how the kiosk visits then proceeded, based on the
214. A number of the medical witnesses spoke about the graduated course of
leave, from the closed ward to the open ward, then progressing to escorted
access within the hospital grounds, on to unescorted ground access and then
eventually day leave and overnight leave home, prior to final discharge. It was
indicated that Carole’s progression to the open ward, then escorted access to
the kiosk, followed by escorted access to the hospital ground, was consistent
with this usual graduated process.
215. Ms Stockdale, the senior OT on the ward at the relevant time, explained
very eloquently at the inquest the kind of effect that a walk in the hospital
grounds could have on a patient. Ms Stockdale noted that the walk is in the bush
and there are kangaroos and other wildlife, which can be very beneficial for
patients to see after being kept inside on the ward for long periods. Ms
Stockdale expressed the opinion that these walks “have a huge effect on people’s
mental health and wellbeing, and they come back just so much fuller of life and
living and hope.” 241 Ms Stockdale had noted that Carole seemed extremely keen
to go on the walk that day and had thought it would be good for her to go,
although the decision was always a medical one as to whether it would be
allowed. In her 30 years of experience working in this kind of role, Ms
Stockdale said she had never ever had someone run away on an escorted walk
before, and it had not been within her contemplation that this might occur with
216. The other workers who went on the walk with Carole that morning also had no
concerns that Carole might abscond, right up until the moment she stood up out
of the wheelchair and began to run. Ms Hettihewa said she could not believe it
at first,243 and Ms Willans and Ms Kaur were also very surprised.244 Ms Willans
remembered that Carole seemed “really … tucked in with blankets into the
wheelchair”245 and she seemed frail and thin, and there was no sign that
anything was going to happen until all of a sudden Carole was up and running.246
Ms Willans also indicated she was very surprised at the pace at which Carole was
able to run, given her first impressions. She gave evidence she ran after Carole
as she thought she would quickly collapse and she wanted to be there to catch
her and support her when she did. However, Carole surprised her by continuing on
at a pretty fast run until Ms Willans had to stop for her own health. Carole
then carried on running until she was out of sight. It was very clear to Ms
Willans at that stage that Carole was quite determined to get away from the
217. I am satisfied that none of the staff involved, either the medical staff
and nursing staff who were involved in decisions about Carole having some
escorted leave from Mimidi Park, nor the staff who were escorting Carole on the
walk, had any inkling of what Carole was planning. Her actions took them
entirely by surprise and they did their best to try to call her back, but Carole
was determined to carry out her escape. There was nothing more they could do at
218. All three Consultant Psychiatrists who gave evidence indicated that they
would have been likely to have granted Carole the leave, if they had been asked.
The Mental Health Act requires the least restrictive approach to be applied, and
after successful leave to the kiosk, they believed that escorted leave in the
hospital grounds with a one-to-one nurse would have been appropriate.
219. In hindsight, it is clear that if the medical or nursing staff had been
aware that Carole had been talking to another patient and her husband about
escaping, this would have elevated her level of risk. However, this might simply
have prompted one of the staff to speak to Carole further before granting her
the leave, and it is likely she would have given a firm denial that she was
feeling suicidal. It is very clear that she was very unhappy at being kept
confined on the ward, under close supervision, and putting on weight against her
will, and I believe she had become desperate in her desire to get away. Her
husband, who had previously helped her to do so, was no longer her ally in this
as he had realised she needed treatment in order to get well. Therefore, she
took matters into her own hands.
220. While a further risk assessment on the morning and discussion with a
consultant psychiatrist, as well as better documentation of discussions and
communication would have been preferable, I am not satisfied that these would
have altered the outcome in this case. The evidence supports the conclusion that
Carole had given the impression she was improving and working towards discharge,
and it was appropriate in those circumstances to gradually increase her freedom,
as part of that process. Obviously, the fact that Carole took that opportunity
to run would have meant greater restrictions being imposed upon her return, but
sadly she was unable to be located and brought back to hospital this time.
221. Mr Lampard has made it very clear that he and Carole’s sister and extended
family have come to terms with the fact that Carole died sometime around the
time of her disappearance from hospital on 3 October 2017. I indicated at the
conclusion of the inquest that I am also satisfied that Carole is deceased to
the requisite standard, and that she died on an unknown date around that time,
from an unascertained cause and in an unknown manner. Unfortunately, that does
not give Carole’s loved ones many more answers than they had going in to this
inquest, but at least now they have formal confirmation of her death, which they
already knew in their hearts.
222. All of the evidence indicated that Carole was an amazing person who
suffered from a terrible illness. She managed to live with that illness for many
years and it is important to remember the many things she achieved in her life
in that time. She lived a life of adventure, self-sufficiency and simplicity
that many people in the current day aspire to, and in that way Carole and her
husband were very ahead of their time. They shared a close bond, which I have no
doubt helped Carole to manage her illness much better than if she had been left
to struggle with it on her own. Sadly, at the end, even her husband could no
longer help her to fight it.
223. Although ultimately her eating disorder overcame her, the legacy of
Carole’s death is an improvement in the care and treatment that others suffering
from eating disorders will receive in this State and I hope that the Western
Australian government fulfils its election promise to provide the necessary
funding to implement even greater changes in the future.
S H Linton
Deputy State Coroner
25 January 2022
Mandurah man's call for help to find missing wife Carole Livesey
A MANDURAH man is pleading for help to find his wife, who disappeared in
baffling circumstances five days ago.
A MANDURAH man is pleading for help to find his wife, who disappeared in
baffling circumstances five days ago.
Carole Livesey walked out of the Rockingham Hospital on Tuesday afternoon,
without permission from doctors, and headed to the Waikiki Salvation Army –
a place she had volunteered at in the past.
“She had a bit of lunch and a few cups of coffee, chatted to a few people
before she headed off about 2pm,” volunteer Tamara told 7 News.
Sadly, the 50-year-old has not been seen since.
Ms Livesey’s husband Chris Lampard said he has driven the streets looking
for the 50-year-old but has had no luck in his
“(It’s been) hellish, yeah it’s been awful not knowing where she is or how she
is,” he said.
“It’s been very difficult.”
According to volunteers at the Waikiki centre, Ms Livesey wasn’t herself they
say and seemed down.
She told the volunteers she was going to hitchhike home to Mandurah before she
Mr Lampard says his wife has a distinctive blue cast on her right arm after
fracturing her elbow in a recent fall.
“I’m amazed at just how many people who love her and are scared for her and
really just want her to come back and be well,” he said.
“Just come home.”
Anyone who has seen Ms Livesey or knows of her whereabouts should call police on
Missing Coodanup woman Carole Livesey reportedly sleeping rough