WHITEHURST -v- STATE CORONER OF WESTERN AUSTRALIA [2026] WASC 222

[2026] WASC 222 Page 1 JURISDICTION : SUPREME COURT OF WESTERN AUSTRALIA IN CIVIL CITATION : WHITEHURST -v- STATE CORONER OF WESTERN AUSTRALIA [2026] WASC 222 CORAM : SOLOMON J HEARD : 21 APRIL 2026 FURTHER AFFIDAVIT EVIDENCE FILED 29 APRIL 2026 DELIVERED : 4 JUNE 2026 PUBLISHED : 4 JUNE 2026 FILE NO/S : CIV 2036 of 2025 BETWEEN : MAURETTA WHITEHURST Plaintiff AND STATE CORONER OF WESTERN AUSTRALIA Defendant Catchwords: Coroners Act s 24, s 25 and s 22 - Request for coronial inquest - Suicide in public hospital emergency department - Interests of justice - Cause of death - Coronial investigation of death - Turns on own facts Legislation: Coroners Act 1996 (WA) Coroners Regulations 1997 (WA) -- 1 of 27 -- [2026] WASC 222 Page 2 Result: Application dismissed Category: B Representation: Counsel: Plaintiff : Mr T Lethbridge Defendant : Mr G M Scott Solicitors: Plaintiff : Croftbridge Lawyers Defendant : State Solicitor's Office Case(s) referred to in decision(s): Conway v Jerram [2010] NSWSC 371; (2010) 78 NSWLR 689 Fink v State Coroner of Western Australia [2022] WASC 44 Harmsworth v State Coroner [1989] VR 989 Herron v Attorney General for NSW (1987) 8 NSWLR 601 Mullaley v State Coroner of Western Australia [2020] WASC 264 R v Doogan [2005] ACTSC 74; (2005) 157 ACTR 1 Re State Coroner [2009] WASCA 165; (2009) 38 WAR 553 Veitch v The State Coroner [2008] WASC 187 White v State Coroner of Western Australia [2022] WASC 418 WRB Transport v Chivell [1998] SASC S7002; (1998) 201 LSJS 102 -- 2 of 27 -- [2026] WASC 222 SOLOMON J Page 3 SOLOMON J: Introduction 1 This matter arises from the tragic and shocking death from suicide of a 42-year-old woman, Chrystalle Whitehurst, in an emergency department of a public hospital. By letter dated 3 September 2025, the Acting State Coroner declined to hold an inquest into the death. The plaintiff, Ms Mauretta Whitehurst, is the mother of Chrystalle. Ms Whitehurst asks this court to order the Coroner to hold an inquest into her daughter's death. Background Circumstances of the death 2 Chrystalle Whitehurst (Chrystalle) was an Indigenous woman and a single mother of three children. Particularly in recent years, she had experienced difficulties associated with mental health challenges and substance abuse. She lived in Hedland in the Pilbara region of Western Australia. 3 From at least June 2019, Chrystalle presented at the emergency department (ED) of the Hedland Health Campus well over a dozen times, mainly with mental health issues that commonly included self-harm and/or suicidal ideation. Chrystalle suffered from alcohol dependence, depression, anxiety and borderline personality disorder. 4 Chrystalle attended the Hedland Health Campus on Thursday 9 June 2022, again with suicidal ideation. She was not admitted to hospital on that occasion, but returned home. 5 The next morning, on Friday 10 June 2022 at around 7:30 am, police attended at Chrystalle's residence to follow up on a complaint in which Chrystalle had been the victim of an alleged theft.1 The police officers considered that Chrystalle was intoxicated, was clearly distressed, and spoke of having considered harming herself the night before. Chrystalle agreed for the police officers to take her to the Hedland Health Campus. 6 The Coroner's decision of 3 September 2025 referred to in [1] above (Coroner's decision) sets out the circumstances of Chrystalle's 1 Affidavit of Susan Markham (11 December 2025) (Affidavit of Susan Markham), 417. -- 3 of 27 -- [2026] WASC 222 SOLOMON J Page 4 death. The account is taken from the contemporaneous hospital notes,2 with some supplementation from the many other documents made available to the Acting State Coroner (Coroner). The factual account is not challenged in any substantial way. The account includes the following:3 Circumstances Surrounding the Death Police attended Chrystalle's address and spoke with her that morning at around 7.30 am to get further information about a stealing complaint. Police were not attending Chrystalle's address in response to a welfare request. The attending police officers suspected Chrystalle was intoxicated and noticed she had vomited on herself. She voluntarily disclosed to police she had thought about hurting herself that night but she did not disclose a specific self-harm threat. She also indicated she had consumed a large amount of wine the night before. The police officers offered to convey her to Hedland Health Campus (HHC) ED for medical review. Chrystalle said she felt like the hospital staff did not listen to her or help her, but still agreed to a lift to hospital to speak to medical staff. Chrystalle sat in the back seat of the police vehicle in company with three police officers. During the drive to hospital, Chrystalle spoke with police and the conversation was general in nature. Chrystalle arrived at [Hedland Health Campus] ED at 7.50 am. One police officer went through the ED to see how busy it was while Chrystalle stayed in the vehicle with the other officers. The officer spoke with the triage nurse at about 7.50 am and advised he had been speaking with an intoxicated female for an unrelated matter who had disclosed she had thought about hurting herself last night. The officer advised the nurse that the female was not under arrest, had not been detained under the [Mental Health Act 2014 (WA)] and was a voluntary patient seeking assistance. The officer provided Chrystalle's name and the nurse stated she knew Chrystalle well as she attended hospital regularly for similar incidents. It was noted Chrystalle had advised she did not want to attend hospital as she feels based on previous experiences that staff did not help or support her. The triage nurse told police to bring Chrystalle straight through to a bed and that she could bypass triage. The officer returned to the vehicle and spoke with Chrystalle and said the hospital was going to give her a bed straight away. The officer recalled Chrystalle thanked him and jokingly said it was too early in the 2 The relevant hospital notes are largely contemporaneous and recorded before the incident leading to Chrystalle's death, but also contain a retrospective note written after the event but on the same day and before 11:10 am, which gives further detail of the interaction between Chrystalle and the primary nurse before 8:30 am. 3 Affidavit of Timothy Lethbridge (11 September 2025) (First Affidavit of Timothy Lethbridge), 43 - 45. -- 4 of 27 -- [2026] WASC 222 SOLOMON J Page 5 morning for him to have so much energy, to which they both laughed. They were met outside by the triage nurse, and they all walked together into HHC through the Ambulance entrance at 7.55 am. The triage nurse noted Chrystalle 'went out to police car and [patient] happily walked into bay 6 with myself.' The triage nurse directed Chrystalle to a cubicle at the very end of the hallway (cubicle 6). Police said goodbye to Chrystalle and observed at least two medical practitioners in the room with Chrystalle as they left. The officers departed at 8.00 am. The attending police officers have all confirmed at no stage did they believe Chrystalle was an immediate risk of self-harm or in the mindset of wanting to self-harm. Chrystalle appeared intoxicated but spoke freely and at no stage disclosed immediate thoughts of wanting to self-harm. They believed she had voluntarily gone to hospital with the police, wanting to seek assistance. The triage nurse started assessing Chrystalle in the cubicle at approximately 7.55 am. The assessment lasted about 5 minutes. The triage nurse noted 'presenting complaint - suicidal ideation. Currently seeing therapist and was triggered by the requests from same yesterday, went home and drank large amount of wine, trying to forget and drown out her suicidal thoughts, no active plan today, knows that she needs to live for her kids. Teary.' The triage nurse left the cubicle after the assessment to complete her notes and enter Chrystalle into the system as she had bypassed the normal triage process. Chrystalle was allocated an Assessment Triage Score of 3. Chrystalle was alone in cubicle 6 for 7 minutes from 8.00 am to 8.07 am. The triage nurse noted that Chrystalle 'left bay 6 stating she doesn't want to stay because we don't listen and just leave her in a room.' The triage nurse advised Chrystalle she 'was just putting her on the system and the primary nurse was going to come in and see her, [patient] stated she wasn't staying and next time we see her it will be in a body bag.' Chrystalle walked out of the department at 8.07 am and sat outside the ED entrance. She was upset and crying. The primary nurse and security were made aware and went outside to speak with Chrystalle moments later. The primary nurse comforted Chrystalle and walked back with her to cubicle 6 at 8.12 am. The primary nurse stayed with Chrystalle in cubicle 6 for 19 minutes from 8.12 am to 8.31am. The primary nurse noted Chrystalle was 'obviously frustrated but cooperative. Teary and crying, stating that dialectical behavioural therapy makes her mental status worse.' Chrystalle sat on the bed and explained recent events to the nurse. She said she had been having counselling for the last 6 weeks and 'this had brought up a lot of trauma, which she is having trouble dealing with.' She also said her 'relationship with her ex wasn't good and she was struggling being a single mother of three. She mentioned hating her -- 5 of 27 -- [2026] WASC 222 SOLOMON J Page 6 parents for what they have done to her and stated she had been diagnosed with Borderline Personality Disorder.' The notes record 'Emotional support and reassurance given, [patient] kept stating she was taking up a bed. RN reassured her that this was not the case and that she is doing the right thing by staying to get help. Chrystalle pointed to a scar on her arm, which she confirmed was from self-harm, and said 'I won't do anything silly like that again.' The primary nurse undertook a secondary assessment with consent. This included physical observations, which were unremarkable, and a blood alcohol level of 0.201%. The primary nurse noted '[patient] appeared to be engaging well with nurse, stated she had not had breakfast.' The primary nurse has explained they felt they had established a good rapport with Chrystalle. The primary nurse left Chrystalle alone in the cubicle at 8.31 am to get Chrystalle breakfast. She phoned the kitchen to order the breakfast. She then updated the student nurse and doctor regarding Chrystalle's condition. Then she briefly attended another patient in resuscitation cubicle 2 before going to the staff room to make a cup of tea for Chrystalle. Multiple staff walked near cubicle 6, attending to nearby patients, moving patients, retrieving blankets from immediately adjacent corridor. When the primary nurse returned to cubicle 6 at 8.52 am, the cubicle door was closed and the curtain was completely pulled across, occluding the view into the cubicle. The primary nurse asked the student nurse to open the door because she was holding two cups. On entering the cubicle, they discovered Chrystalle hanging with her purse cord looped around her neck and tied to the above-bed examination light. 7 The hospital notes record that resuscitation efforts began at 8:53 am. It appears, therefore, that Chrystalle took the action that led to her death in the period of just over 20 minutes during which she was left alone in bay 6. 8 After some limited clinical success in resuscitation, Chrystalle was transferred by air to a hospital in the Perth metropolitan area. Chrystalle did not recover and tragically died on 20 June 2022. Investigation into the death 9 Shortly after Chrystalle's death, an investigation into Chrystalle's death was carried out by the WA Country Health Services (WACHS). The investigation produced two documents in August 2022. One is titled 'Confidential SAC1 Clinical Investigation Report CIMS341750' (WACHS Report). The other is titled 'Clinical Incident Investigation Summary Report - CIMS341750' (WACHS Summary Report). Both -- 6 of 27 -- [2026] WASC 222 SOLOMON J Page 7 documents were in tendered in evidence.4 It appears that the WACHS Report was prepared for the WACHS's own investigative purposes and was ultimately provided to the Coroner. The WACHS Summary Report was in the form of an overview. It was directed to the concerns of Chrystalle's family and was expressly addressed to them. 10 In addition to an account of the circumstances of Chrystalle's death, the WACHS Report set out in a detailed table the investigation's findings and recommendations. The table set out each of the identified problems in Chrystalle's treatment. The problems included: the failure to observe Chrystalle adequately in bay 6; allowing Chrystalle to keep her personal belongings; putting Chrystalle in an area with ligature points; and the failure to recognize the immediate risk of self-harm. For each of those problems, the report set out in detail the contributing factors, the WA Health Department's view of the cause, and the recommendations to address those matters. 11 A number of recommendations were made by the WACHS Report. These included: the issuing of clinical alerts regarding the requirements for observation of mental health patients from arrival; tools for triage and other measures to enhance appropriate cubicle allocation and visibility of mental health patients to facilitate 10-minute visual observations; consideration of remote electronic visibility; and environmental safety measures including the possible removal of ligatures. A further detailed table set out the recommendations, who the relevant task was assigned to, the due date, and the outcome measure. 12 The WACHS Summary Report outlined the process of the investigation and dealt with a range of issues. The report examined Chrystalle's mental health condition, the risk it posed, and the response of the hospital staff to that risk in the circumstances. The report addressed a number of concerns, including the failure to contact family when Chrystalle presented to the hospital, the failure to call on a mental health practitioner immediately, the failure to remove personal belongings, the choice of bay 6 which did not provide visibility, and the length of time that Chrystalle was left alone. The report acknowledged improvements that ought to be made, some of which had been implemented, particularly in respect of the frequency of observations and the visibility of a patient. 13 A 'Report to the Coroner' from the Coronial Investigation Squad of WA Police, dated 11 August 2023, fairly summarised the WACHS 4 Affidavit of Susan Markham, 379 - 396; First Affidavit of Timothy Lethbridge, 12. -- 7 of 27 -- [2026] WASC 222 SOLOMON J Page 8 Report as identifying 'four problems with the care that was provided' at Hedland Health Campus. Consistent with the WACHS Report, these were:5 (1) the deceased was not continuously observed from arrival in the department; (2) the deceased retained her personal belongings which were used to self-harm; (3) the deceased was allocated a room with ligature points; and (4) the deceased was not recognised to be at a risk of immediate self-harm. Coroner's investigation 14 By letter dated 18 August 2023, the Aboriginal Legal Service, on behalf of Ms Mauretta Whitehurst (Ms Whitehurst), requested an inquest into Chrystalle's death pursuant to s 24(1) of the Coroners Act 1996 (WA) (the Act). 15 A considerable and comprehensive volume of documents was made available to the Coroner in the course of her consideration of the request. These documents included hospital and clinical notes and records from the Hedland Health Campus, the Department of Health, Perth Clinic, and WA Country Health Service, as well as reports and notes from mental health practitioners and entities that had treated Chrystalle in the past. These records related not only to Chrystalle's death and the hospital admission that immediately preceded it, but included records dating back some years. 16 The documents also included various police reports relating to Chrystalle's death and postmortem laboratory reports, as well as the WACHS Report and the report of the Coronial Investigation Squad referred to above. 17 In addition, by letter dated 25 March 2024, counsel assisting the Coroner wrote to a consultant forensic psychiatrist, Dr Victoria Pascu (Dr Pascu), regarding the Coroner's investigation into Chrystalle's death. Dr Pascu was provided with comprehensive documentation 5 Affidavit of Susan Markham, 422. -- 8 of 27 -- [2026] WASC 222 SOLOMON J Page 9 regarding Chrystalle's medical history and her death. The letter sought Dr Pascu's expert opinion in relation to the following nine matters:6 (a) Whether the ATS of 3 was appropriate; (b) Whether Dr Pascu considered that Ms Whitehurst was an immediate or high risk of self-harm when she presented to HHC ED on 10 June 2022, and if so, whether this risk was appropriately recognised and managed by staff; (c) Whether hospital staff should have searched Ms Whitehurst and her belongings before being allocated an ED cubicle; (d) Whether staff should have removed any dangerous items from Ms Whitehurst, such as items that could be used to create a ligature, such as a bag strap; (e) Whether Ms Whitehurst should have been considered/allocated a 1:1 nurse special in ED; (f) Whether staff should have contacted a member of Ms Whitehurst's family, or an Aboriginal Health Worker, to support her in the ED; (g) Whether Ms Whitehurst's suicide was predictable and/or preventable; (h) HHC was completed in 2010 and is described on the WACHS website as a modern purpose-built facility. It services a population of about 15,000. The ED did not have a ligature free room when Ms Whitehurst presented. In this context, is there any concern that there was not an appropriate cubicle/bay for containment of mental health patients in this WACHS ED; and (i) Whether the standard and quality of care provided by HHC was below the standard of care expected of hospital in the Pilbara region. 18 Dr Pascu's report is dated 5 August 2024. The report provides an account in some detail of Chrystalle's medical history, including her mental health, presentations to hospital, and the circumstances of her death. 19 After a detailed account and analysis, Dr Pascu addressed the specific questions she had been asked. Dr Pascu's opinion and answers may be summarised as follows: 6 Affidavit of Susan Markham, 426 - 427. -- 9 of 27 -- [2026] WASC 222 SOLOMON J Page 10 (1) A triage assessment of Assessment Triage Score (ATS) of level 3 was appropriate in the circumstances. That assessment required visual observations at a maximum of 10 minutes to monitor for self-harm or suicide risk. (2) The circumstances indicated an increased risk of self-harm and suicide from Chrystalle's baseline chronic risk, but did not indicate an imminent risk. (3) In the circumstances, searching or removing Chrystalle's personal property would have been regarded as an infringement of Chrystalle's rights, and might have escalated her risk to herself and others. (4) There was no indication in the circumstances that a 1:1 nurse continuous observation was required. (5) Having an Aboriginal Health or Mental Health Worker present is the recommended best clinical practice and would have helped in engaging Chrystalle in any assessment in a culturally appropriate way and providing support in the ED environment. (6) Visual observation every 10 minutes might have mitigated the risk to Chrystalle, but it is difficult to say whether it would have prevented her death. Suicide is a rare event and extremely difficult to predict. A person's suicidality can fluctuate in a very short timeframe. (7) Authorised mental health facilities are 'anti-ligature environments' but emergency departments are not authorised mental health facilities. That aside, cubicle 6 was appropriate for providing privacy and reduced sensory stimulation, and was chosen for clinical reasons. However, the obstacles to clear observation and its distance from the nursing station meant it was not a suitable place to manage Chrystalle. (8) The standard of care provided was overall in line with the standards of care expected of general hospital emergency departments in Western Australia where often there is less than adequate infrastructure. (9) Dr Pascu set out the following recommendations:7 7 Affidavit of Susan Markham, 448 - 449. -- 10 of 27 -- [2026] WASC 222 SOLOMON J Page 11 - Ensuring that safe, low stimulus area with good visibility is developed in Port Hedland Hospital ED to provide safe assessment and management of patients with mental health issues while in ED. - Need for WACHS ED clinical staff to be aware of the requirements of the Clinical Practice Standards dated 25 February 2021 regarding levels of close observation of mental health patients from arrival to ED until a comprehensive mental health assessment and management plan is formulated. Clinical staff at triage identified the correct triage level at ATS 3 and managed this accordingly however staff did not manage the level 3 risk in a person presenting with mental health issues. This would have included closer visual monitoring at a maximum of 10 minutes. - Education of non-mental health clinical staff regarding the need to conduct a basic risk assessment and involving mental health staff in the development of comprehensive mental health risk assessment and management plans as soon as possible after their arrival to ED. - Clinical front line non mental health staff will require ongoing education and support from mental health staff in the management of patients with borderline personality disorder with repeated presentations to ED in crises. - Patients with borderline personality disorder, in particular the patients with frequent ED presentations will require clear management plans formulated by the community mental health team to provide clear guidance to ED staff regarding the management of the patient during their ED presentations. - Ensuring that patients have access to culturally appropriate assessments and interventions and involvement of their families and support people in the comprehensive assessment and development of comprehensive management plans. - Education to non-mental health clinical staff regarding the DOH 'Principles and best practice for the care of people who may be suicidal' to help conducting the initial risk assessments for patients presenting to EDs with mental health issues. Involving mental health staff in education and training to help increase confidence in conducting these assessments. - Ongoing education to clinical (mental health and non-mental health) staff regarding need for collateral information from those close to the patient when conducting comprehensive risk assessments and management plans. -- 11 of 27 -- [2026] WASC 222 SOLOMON J Page 12 - Requirement of contemporaneous clinical documentation and discharge summaries following every presentation to ED. 20 Two expert reports were obtained and tendered in support of Ms Whitehurst's request for an inquest. 21 The first is from The Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention, which is a centre within the School of Indigenous Studies at the University of Western Australia. The report is in the form of letter to the Coroner dated 18 December 2025, following the Coroner's decision. The report references the disproportionately high level of suicide among Aboriginal people, and notes statements of Chrystalle illustrating the 'lack of cultural safety of mainstream services and the importance of Aboriginal Health Workers'.8 The report explained that this deficiency contributes to Indigenous people's hesitancy in seeking help and statistically high incidence of leaving hospital without treatment. The report also made reference to the need for interpreters, and the prevalence of unconscious bias and its association with racism. The report acknowledged that since the death of Chrystalle, there have been developments and improvements in mental health services in Hedland and a greater recognition of the principles underpinning the best approaches to suicide prevention in Aboriginal people. The report provided other examples of improved approaches in Western Australia. The report concluded by acknowledging that it is not possible to predict an individual suicide from known risk factors, but that 'each passing of an Aboriginal … suicide may provide opportunities for understanding and [learning] that may be used to prevent losses in the future'. In that spirit, the report supported the request for an inquest. 22 By letter dated 22 October 2025, lawyers for Ms Whitehurst sought the opinion of a specialist emergency medicine physician, Dr Chris Cheeseman. The specific questions put to Dr Cheeseman included:9 Was Chrystalle's care in ED appropriate, and in particular: (i) Was an ATS risk level of 3 an appropriate risk level to allocate Chrystalle; (ii) Was it appropriate to conclude that Chrystalle was not at an immediate risk of self- harm at the time she presented at ED; 8 Affidavit of Timothy Lethbridge (22 January 2026) (Second Affidavit of Timothy Lethbridge), 8. 9 Second Affidavit of Timothy Lethbridge, 23. -- 12 of 27 -- [2026] WASC 222 SOLOMON J Page 13 (iii) Did the staff in the ED properly take into account Chrystalle's intoxication, previous hospitalisations, suicide attempts and mental health issues; (iv) Was Chrystalle's care generally in line with that of hospital EDs in Australia; (v) Was the allocation of Chrystalle to a cubicle that contained ligature points and allowed the patient to be out of view of hospital staff appropriate under the circumstances?; (vi) Was a 1:1 nursing special where a patient is constantly monitored warranted in Chrystalle's situation. 23 Dr Cheeseman's report was dated 3 December 2025. In summary, Dr Cheeseman's opinion included the following:10 (1) The triage assessment and initial reception of Chrystalle was undertaken in a diligent manner and indeed 'far exceeded' what would normally be expected in most Australian emergency departments. (2) The ATS risk assessment of level 3 was appropriate. Chrystalle did not demonstrate any concerning features or signs that she presented an immediate risk to herself. (3) There was no indication that constant supervision was required of Chrystalle due to her clinical condition. (4) Unsupervised spaces are common in most emergency departments in Australia. However, an acceptable standard of care is that no patient should be left unsupervised in a clinical space that cannot be observed. Bay 6 reflects a design that is not unusual; however, given that it was not directly observable, it was not an appropriate space in which to leave a patient without supervision. (5) There was no indication that constant supervision was required of Chrystalle due to her clinical condition. (6) Allocating bay 6 'was not wholly inappropriate, given the stated objectives of reducing stimulus', but it was not a safe location for a mental health patient without supervision and observation, particularly given the number of ligature points available in that clinical space. 10 Second Affidavit of Timothy Lethbridge, 68 - 80. -- 13 of 27 -- [2026] WASC 222 SOLOMON J Page 14 (7) Given the relatively small size of the department and paucity of clinical spaces, it may be hard to justify a dedicated room for mental health patients which is observable and free of ligature points. (8) While there was no indication that constant supervision of Chrystalle was required, the choice of a non-observable area with a significant number of ligature points and the absence of a search of Chrystalle's property meant that constant supervision of Chrystalle was 'indicated', and would likely have avoided the self-strangulation. (9) A reasonable standard of care would require all mental health patients to have their property searched. With voluntary patients, this cannot be done without consent. However, a refusal to give consent would indicate a higher level of observation was required. Had that been done with Chrystalle, her death may well have been avoided. 24 Dr Cheeseman produced a supplementary report dated 21 January 2026 based upon further information provided to him. Dr Cheeseman's opinions did not change in any substantial way in the supplementary report. He reiterated that Chrystalle's self-inflicted strangulation was 'an unpredictable event which could not have been anticipated nor predicted' and there was no indication that an increased level of supervision was required; however, bay 6 was an unsuitable space in which to leave Chrystalle, or indeed any patient, without supervision.11 Dr Cheeseman added that he agreed with Dr Pascu that access to an Aboriginal Health Worker may have been particularly beneficial for Chrystalle. Dr Cheeseman highlighted however that 'the timeframe that [Chrystalle] was in the Emergency Department was not conducive to accessing this resource, given the time of day and the short duration of time in the Emergency Department'.12 25 The evidence before this court included a letter from the Acting Principal Registrar of the Coroner's Court, Ms Susan Markham, to the Chief Executive Officer of the WACHS, dated 6 March 2025.13 The letter responds to correspondence from the WACHS dated 15 August 2023. I was unable to locate that correspondence in the materials provided to the court; however, it appears that it may have been a 11 Second Affidavit of Timothy Lethbridge, 106 - 107. 12 Second Affidavit of Timothy Lethbridge, 108. 13 Affidavit of Susan Markham, 580 - 581. -- 14 of 27 -- [2026] WASC 222 SOLOMON J Page 15 covering letter which provided the WACHS Report to the Coroner. The letter refers to the WACHS Report and states that the Coroner was greatly assisted by it. The letter also refers to the report of Dr Pascu. 26 The letter records that on 21 February 2025, the Coroner 'determined that this case could appropriately be finalised by way of Administrative Finding rather than an inquest'.14 That advice was not conveyed to Chrystalle's family. It appears that the Coroner deferred formalising the decision to provide Chrystalle's family with further opportunities to inspect documents and make further submissions. By letter dated 4 July 2025, Ms Whitehurst (through the law firm Croftbridge) wrote anew to the Coroner requesting an inquest.15 The response to that request was provided by the Coroner's decision. Coroner's decision 27 Section 22(1) of the Act sets out the circumstances in which an inquest is mandatory. In contrast, the Coroner's decision was made pursuant to s 22(2) of the Act, which provides that a 'coroner who has jurisdiction to investigate a death may hold an inquest if the coroner believes it is desirable' (emphasis added). 28 The Coroner's decision sets out the circumstances of Chrystalle's death, the basis for Ms Whitehurst's concerns, and the reasons for her request for an inquest. The Coroner's decision considered the public interest in access to mental health services, particularly for Aboriginal people living in the Pilbara. The Coroner examined the available options. The Coroner's decision then turned to the improvements that had been adopted since Chrystalle's death to address the identified concerns, and further measures that were planned to address those concerns. The Coroner's decision considered the WACHS Report and the report of Dr Pascu, and the conclusions and findings of those reports. 29 The Coroner made the following remarks regarding the observation of Chrystalle while she was in bay 6:16 With the considerable benefit of hindsight, it is unfortunate the primary nurse did not check-in with Chrystalle between tasks. However, as noted above, someone who is hanging only has minutes before they suffer severe or fatal injuries. We do not know exactly when Chrystalle hung herself and an inquest will not provide an answer to this. Although 14 Affidavit of Susan Markham, 580. 15 First Affidavit of Timothy Lethbridge, 2 - 40. 16 First Affidavit of Timothy Lethbridge, 52. -- 15 of 27 -- [2026] WASC 222 SOLOMON J Page 16 an opportunity was lost to observe Chrystalle within 10 minutes, it cannot be said with any certainty that the ultimate outcome would have been prevented had the primary nurse checked in with Chrystalle at or before 8.41 am; she may have already hung herself. The facts surrounding Chrystalle's observations by staff are well established. The WACHS SAC 1 Clinical Investigation found Chrystalle was not appropriately observed. As already discussed, several recommendations were made by WACHS to address this issue. As mentioned above, Dr Pascu was of the view that an ATS score of 3 was appropriate, Chrystalle did not present as an immediate risk of harm, and that a 1:1 nursing special was not necessarily warranted. The SAC 1 panel issued an alert to all WACHS EDs reminding them of the requirement to follow Clinical Practice Standards including observation of mental health patients from arrival. 30 The Coroner's decision set out its conclusions relating to Chrystalle's death in the following paragraph:17 Chrystalle engaged with various mental health service in the lead up to her death. A number of other services were available for her to access, but she preferred to engage with private mental health providers. Chrystalle reported to staff she was receiving various forms of psychotherapy treatment for [borderline personality disorder] in the months and weeks leading up to her death. She did not present as an immediate risk of self-harm or suicide to staff on 10 June 2022. There was a missed opportunity for staff to visually observe Chrystalle and there was an 11-minute delay between observations. Staff's ability to observe Chrystalle was impacted by her cubicle allocation and use of a cubicle curtain. The reasons for cubicle allocation and for the delay have been explained and do not appear entirely unreasonable in the circumstances. These issues were clearly acknowledged by WACHS in their [WACHS Report] and made various recommendations to improve staff observations and cubicle safety. In the 3 years following the death, there have been relevant improvements to mental health in South Hedland and the Pilbara with future improvements in development. Suicide prevention, including the prevalence of suicide among Aboriginal people, is recognised, co-ordinated and funded on a regional, State and Federal level. 31 In declining to hold an inquest, the Coroner recorded that she was satisfied that all proper lines of enquiry had been undertaken and exhausted, and that an inquest was not likely to generate further evidence that will assist in making the findings that the Coroner was required to make. The Coroner added that she did not think that the 17 First Affidavit of Timothy Lethbridge, 54. -- 16 of 27 -- [2026] WASC 222 SOLOMON J Page 17 ultimate outcome - that is, Chrystalle's death - 'could have been predicted or prevented'.18 Application to the Supreme Court 32 The Originating Motion by which this this proceeding was commenced set out the grounds for the request. The request was based on the contention that an inquest is likely to elicit new evidence that was not disclosed by the Coroner's enquiries. That is said to be because the conclusions of the WACHS Report are inconsistent with findings that are likely to be reached if the evidence is tested by an inquest. The grounds contended that the Coroner's investigations gave insufficient consideration to the following matters, each of which, if properly addressed, might have avoided Chrystalle's death: (1) the wider issues affect affecting the provision of mental health services for patients in the Pilbara region; (2) the particular difficulties associated with patients with borderline personality disorder; and (3) the particular needs of Indigenous people with mental health issues in the Pilbara region. 33 In written submissions, counsel for Ms Whitehurst directed particular attention to a number of matters. 34 Counsel for Ms Whitehurst referred to the oft-repeated statement that suicide is generally not something that can be predicted. Counsel submitted that reliance on that proposition obscured the necessity to examine the particular factors that may have avoided Chrystalle's death. Similarly, it was submitted that, whilst there was an acknowledgement that with hindsight various measures would have been preferable, there was no real acknowledgement of how those matters may have actually been causative of Chrystalle's death. 35 Counsel for Ms Whitehurst was also concerned that insufficient attention had been given to the adoption of a process whereby a patient is searched for personal belongings, or at least asked if they consented to being searched. 36 Counsel for Ms Whitehurst expressed further concern that insufficient attention had been directed to the question of why locally 18 First Affidavit of Timothy Lethbridge, 42. -- 17 of 27 -- [2026] WASC 222 SOLOMON J Page 18 available mental health services had not been utilised. In addition, insufficient attention had been given to the particular diagnosis of borderline personality disorder and how that ought to have impacted on the treatment received upon presentation to the ED. 37 In support of the application, counsel for Ms Whitehurst also relied upon a number of academic articles. These concerned appropriate treatment for, and the particular suicide risk of, patients suffering from borderline personality disorder, and more generally, coronial investigations of deaths of patients with psychiatric illness from suicide. 38 Ms Whitehurst also gave oral evidence at the hearing. Her evidence reflected a deep concern not only for what her daughter endured, but for the plight of others who suffer from mental health challenges, and all the more for those with borderline personality disorder. Ms Whitehurst expressed particular concern for Indigenous patients. Her daughter told her that she did not feel that her illness was being taken seriously. Chrystalle told her mother, 'because I'm Aboriginal, they just think I'm just another drunk'.19 Ms Whitehurst felt that such an attitude was pervasive, and that Indigenous patients were disadvantaged by such attitudes. 39 There was a haunting sadness but a resolute strength in Ms Whitehurst's evidence. She spoke both forcefully and respectfully. I was left with no doubt as to the genuineness and authenticity of her evidence. Ms Whitehurst was a persuasive and eloquent advocate for those who endure the tragedy that plagued her daughter. Legal principles 40 The Act provides for a coronial system to inquire into Western Australian deaths.20 Under pt 2 of the Act, that system includes the establishment of the Coroner's Court of Western Australia, the office of State Coroner and the appointment of coroners (including the State Coroner and the Deputy State Coroner).21 The functions of the State Coroner include ensuring that all reportable deaths are investigated and 19 ts 18. 20 The long title to the Coroners Act 1996 (WA) states that it is: 'An Act to establish the office of State Coroner, to provide for a State coronial system to inquire into Western Australian deaths, to repeal the Coroners Act 1920, to amend certain other Acts and for related purposes.' 21 Coroners Act 1996 (WA) pt 2. -- 18 of 27 -- [2026] WASC 222 SOLOMON J Page 19 to hold an inquest whenever there is a duty to do so under the Act or whenever it is desirable to hold an inquest.22 41 Much of the Act is concerned with reportable deaths. A reportable death is defined in s 3 of the Act. It includes a death that that appears to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from injury.23 It is uncontroversial that Chrystalle's death was a reportable death. 42 Part 4 of the Act deals with the investigation of deaths by a coroner. Under s 19, a coroner has jurisdiction to investigate a reportable death. Division 2 of pt 4 provides for the coroner's powers of investigation. Those powers include such things as restriction of access, powers of entry, inspection and possession, post-mortem examination and exhumation. 43 In certain prescribed circumstances set out in s 22(1), the investigation must take the form of an inquest. For example, if the person died while in custody or the death was caused by the action of a police officer, the investigation must take the form of an inquest. An inquest is different from a general investigation into a reportable death because it is a formal hearing by the Coroner's Court. The special powers and processes associated with an inquest are set out in pt 5 of the Act. 44 The Act prescribes the matters that the coroner must (if possible) find in the investigation of a death. Section 25(1) provides that: A coroner investigating a death must find if possible - (a) the identity of the deceased; and (b) how death occurred; and (c) the cause of death; and (d) the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1998. 45 Section 25(2) provides that a 'coroner may comment on any matter connected with the death including public health or safety or the administration of justice'. 22 Coroners Act 1996 (WA) s 8. 23 Coroners Act 1996 (WA) s 3, 'reportable death'. -- 19 of 27 -- [2026] WASC 222 SOLOMON J Page 20 46 The matters prescribed by s 25 are applicable to every coroner's investigation into a death, regardless of whether or not the investigation takes the form of an inquest. 47 Section 26(1) provides that a coroner or the coroner's registrar must keep a record of each investigation into a death in the prescribed form. That too applies to every investigation, regardless of whether the investigation took the form of an inquest. Regulation 6 of the Coroners Regulations 1997 (WA) (the Regulations) provides that the record of investigation required by s 26(1) is to be in the form of Form 3 of the Regulations.24 Form 3 requires the record to show whether the investigation was conducted '[w]ithout holding an inquest' or '[w]ith an inquest held at …'. Consistently with s 25, Form 3 provides for the recording of the identity of the deceased person, the cause of death, and the circumstances of the death. There is also provision for the coroner's 'Comments'. 48 If a death is not one that requires the coroner to hold an inquest, the coroner may nevertheless do so. Section 22(2) provides that a 'coroner who has jurisdiction to investigate a death may hold an inquest if the coroner believes it is desirable'. 49 Chrystalle's death did not come within the circumstances set out in s 22(1). The Coroner was therefore not required to hold an inquest. However, under s 22(2), the Coroner was able to hold an inquest if the coroner believed that was desirable. The Coroner plainly did not consider it desirable and did not hold an inquest. 50 Section 24 of the Act is the basis for this application. It provides: (1) If a person asks a coroner to hold an inquest into a death which a coroner has jurisdiction to investigate, the coroner may - (a) hold an inquest or ask another coroner to do so; or (b) refuse the request and give reasons in writing for the refusal to the person and to the State Coroner within a reasonable period after receiving the request. (1a) A request under subsection (1) is to - (a) be made in writing; and (b) contain reasons for the request. 24 Coroners Regulations 1997 (WA) r 3. -- 20 of 27 -- [2026] WASC 222 SOLOMON J Page 21 (2) Within 7 days after receiving notice of the refusal, or if a reply to a request for an inquest to be held has not been given within 3 months after the request was made, the person may apply to the Supreme Court for an order that an inquest be held. (3) The Supreme Court may make an order that an inquest be held if it is satisfied that it is necessary or desirable in the interests of justice. 51 As explained, Ms Whitehurst made a request for an inquest through the Aboriginal Legal Services on 18 August 2023 and a further request through Croftbridge law firm dated 4 July 2025. Pursuant to s 24(1), the Coroner refused the request and provided reasons in the Coroner's decision. Ms Whitehurst then brought this application under s 24(2). 52 Under s 24(3), this court may grant the request for an inquest 'if it is satisfied that it is necessary or desirable in the interests of justice'. A decision that it is necessary or desirable in the interests of justice that an inquest be held involves a discretionary value judgment.25 53 The words 'in the interests of justice' are words of the 'widest possible reference. Indeed, there could scarcely be a wider judicial remit'.26 54 In determining what is encompassed by 'the interests of justice', regard is to be had to the evident policy and objects of the legislation.27 In evaluating whether it is necessary or desirable in the interests of justice that an inquest be held, regard must be had to the scope and focus of an inquest when one is held. The scope of an inquest is affected by s 25 of the Act.28 Section 25(1) of the Act states exhaustively the jurisdiction of a coroner in relation to the ultimate findings or decisions which a coroner investigating a death is entitled and obliged (if possible) to make.29 55 The scope of a coroner's investigation in respect of the identity of the deceased required by s 25(1) is generally not difficult to determine. In contrast, the scope of the enquiry regarding how the death occurred and the cause of death has been the subject of considerable commentary. The authorities were considered by Buss JA in Re State 25 Veitch v The State Coroner [2008] WASC 187 [35]. 26 Herron v Attorney General for NSW (1987) 8 NSWLR 601, 613. 27 Veitch v The State Coroner [36]. 28 Veitch v The State Coroner [38]. 29 Re State Coroner [2009] WASCA 165; (2009) 38 WAR 553 [52]. -- 21 of 27 -- [2026] WASC 222 SOLOMON J Page 22 Coroner. The following observations are largely taken from the reasons of Buss JA. 56 The expression 'how death occurred' in s 25(1)(b) of the Act must be construed not merely by reference to its dictionary meaning, but also in the context of the other provisions of s 25(1) and the Act as a whole.30 The expression 'does not refer only to the means or mechanism by which the death was suffered or inflicted. It extends to the circumstances attending the death'.31 57 The expression 'cause of death' in s 25(1)(c) is not confined or restricted by concepts such as 'direct cause', 'direct or natural cause', 'proximate cause' or the 'real or effective cause'.32 The inquiry is not limited to the immediately proximate circumstances. Other facts less proximate in time will be relevant as a cause of death. The limits of the inquiry are determined by common sense.33 58 Section 25(1)(c) does not, however, authorise a coroner to undertake a 'roving' commission for the purpose of inquiring into any possible causal connection between a circumstance and the death of the deceased. It will be necessary, in each investigation, to delineate those circumstances which are to be characterised as causing or a cause of the death of the deceased.34 This is to be undertaken by applying ordinary common sense and experience to the facts of the particular case.35 59 The ability of the coroner to comment provided by s 25(2) of the Act does not widen the scope of the coroner's function. The power to comment arises as a consequence of the obligation to make findings.36 The ultimate findings or decisions under s 25(1) circumscribe the matters connected with the death (including public health or safety or the administration of justice) in respect of which the coroner may comment under s 25(2) of the Act. That is, the coroner's role under s 25(2) is ancillary to the role under s 25(1). 60 It follows that, notwithstanding the undoubted breadth of the expression 'in the interests of justice', the discretion must be exercised 30 Re State Coroner [41]. 31 Re State Coroner [42]. 32 Re State Coroner [44]. 33 WRB Transport v Chivell [1998] SASC S7002; (1998) 201 LSJS 102 [21]. 34 Re State Coroner [46] - [47]. 35 See, also, R v Doogan [2005] ACTSC 74; (2005) 157 ACTR 1 [28] - [29]. 36 Harmsworth v State Coroner [1989] VR 989, 996. -- 22 of 27 -- [2026] WASC 222 SOLOMON J Page 23 by reference to the function of the coroner as exhaustively prescribed by s 25(1).37 61 In Mullaley v State Coroner of Western Australia,38 Le Miere J considered the request for an inquest in respect of the death of 10-month-old boy. The boy's death had been investigated by the Major Crime Squad and was the subject of a criminal trial at which a man had been found guilty of the boy's murder. Le Miere J set out eight reasons for his conclusion that it was not necessary or desirable in the interest of justice that an inquest be held. 62 The reasons expressed by Le Miere J relevantly considered the following points:39 (1) whether the inquest was likely to elicit new evidence; (2) whether the inquest was likely to find new facts or clarify the facts around deceased's death; (3) the fact that the function of an inquest is to find facts around the death, not to attribute criminal or civil liability or blame for the death beyond findings necessary for the finding of 'how death occurred'; (4) the matters and circumstances which the plaintiff wished the coroner to investigate, in the context of the entirety of the circumstances leading to the death; (5) whether there was doubt as to the cause of death; (6) whether the inquest was requested for the sole or substantial reason of the coroner making comments or recommendations; and; (7) the inconvenience an inquest will cause to those required to give evidence about a traumatic incident, and the hurt and pain to some of them, and the expense of holding an inquest. 63 The points set out by Le Miere J have, in subsequent cases, been regarded as 'factors' to which the court may have regard in exercising 37 See, also, Conway v Jerram [2010] NSWSC 371; (2010) 78 NSWLR 689 [35]. 38 Mullaley v State Coroner of Western Australia [2020] WASC 264 (Mullaley). 39 Mullaley [130] - [138]. -- 23 of 27 -- [2026] WASC 222 SOLOMON J Page 24 its discretion under s 24(3) of the Act.40 Those same cases have also made reference to the principle that the power in s 24(3) is to be exercised sparingly and in rare cases.41 64 I would respectfully make two observations in that regard. 65 First, the discretionary power conferred by s 24(3) is framed in broad terms. It is constrained only by the objects of the Act. Although the factors referred to in Mullaley may provide useful guidance in some cases, they cannot detract from the breadth of the discretion. They are no more than the reasons that the court considered to be relevant in that matter. Neither Le Miere J in Mullaley, nor the cases that followed, suggested otherwise. 66 Secondly, if the court is persuaded that the holding of an inquest is necessary or desirable in the interests of justice, then an inquest should ordinarily be ordered. I do not think that the exercise of the discretion should be trammelled by a disposition to regard that outcome as 'rare' or by a presumption that the power should be used 'sparingly'. Consideration 67 Chrystalle's death involved the catastrophic intersection of grave mental illness, substance addiction, and the systemic disadvantage endured by Indigenous communities and individuals. It is hard to imagine three more pressing issues that breed dysfunction, human misery and injustice in contemporary Australia. If the statutory power turned on the interests of justice from a societal perspective, there could be only one answer to the question of whether an inquest should be ordered. 68 Inquisitorial processes that address the ills and evils of society take the form of governmental enquiries or Royal Commissions. An inquest under the Act is also inquisitorial. It is an inquiry conducted by the coroner, not a proceeding between parties. However, as explained above, the discretionary power conferred on this court by s 24(3) in respect of an inquest is confined. The power is conferred, and must be understood, in the context of the statutory role and function of the coroner, and the parameters of the coroner's jurisdiction in the investigation of a death as prescribed by s 25 of the Act. 40 See White v State Coroner of Western Australia [2022] WASC 418; Fink v State Coroner of Western Australia [2022] WASC 44. 41 White v State Coroner of Western Australia [88]; Fink v State Coroner of Western Australia [115]. -- 24 of 27 -- [2026] WASC 222 SOLOMON J Page 25 69 Chrystalle's death has been the subject of comprehensive consideration. As set out above, this included various police reports, including that of the Coronial Investigation Squad, the WACHS Report, Dr Pascu's report and the reports obtained by lawyers for Ms Whitehurst, Dr Cheeseman's report, Dr Cheeseman's supplementary report, and the report from the University of Western Australia's Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention. The reports not only comprehensively examined the circumstances of Chrystalle's death, but analysed in some depth the processes and causes of what transpired, and provided assessments of Chrystalle's treatment and recommendations about how matters could be better managed. 70 Chrystalle's family, and Ms Whitehurst in particular, continue to bear the anguish of wishing to leave no stone unturned in examining what might have been done to prevent Chrystalle's death, and what could be done to prevent others from suffering such a fate. Their torment is understandable. Their concern for others is more than commendable. 71 In that vein, the statement in the Coroner's decision that the outcome could not have been prevented would be understandably distressing to Chrystalle's family. In hindsight, there are plainly things that had they been done, Chrystalle's death may not have occurred. But the Coroner's decision needs to be understood in the context of the enquiries that were undertaken, and the thorough and professional assessments that were made. The Coroner's remarks and conclusion are directed to, whether in the circumstances, it was reasonable to have expected measures to have been taken that would have prevented Chrystalle's death. 72 In all the circumstances, I am not persuaded that an inquest will achieve the outcome that grounds this application - that it will elicit new evidence not disclosed by the enquiries already undertaken. Of course, it is entirely possible that in a broad sense, new evidence may indeed come to light. But to warrant the granting of the application, such new evidence must be relevant to the coroner's statutory function under s 25 of the Act. In light of the comprehensive nature of the existing reports, including the reports obtained from Dr Cheeseman and the University of Western Australia, I do not consider it likely that such new evidence will emerge. -- 25 of 27 -- [2026] WASC 222 SOLOMON J Page 26 73 The most troubling aspect of Chrystalle's treatment and death appear to be the allocation of a cubicle containing ligatures with limited visibility, and the failure to meet the requirement for observation every 10 minutes. These deficiencies have been clearly identified by each of the reports and appropriate recommendations have been made. The reports, including the expert report procured and tendered on behalf of Ms Whitehurst, nevertheless regard Chrystalle's death as a tragedy that could not have been predicted. The question of what might have been will forever haunt those involved. The sad reality is that no amount of further enquiry is likely to resolve that question. 74 Turning to the scope of the coroner's investigative function, the identity of Chrystalle was plainly never in issue. The matters in issue relevant to the coroner's investigation are the matters raised by s 25(1)(b) and (c): how Chrystalle's death occurred and the cause of her death. In my assessment, those matters have been dealt with fairly and thoroughly by the existing reports, which adequately address the scope of the coroner's investigative function as explained above. To the extent that measures could or should have been undertaken that might have prevented or at least reduced the prospect of Chrystalle's death, those measures have been identified and discussed in the existing reports. 75 I accept that the reports leave unanswered or unaddressed broader issues relating to challenges presented by the harrowing matters I have referred to at [67]. However, they are matters beyond the proper scope of the coroner's investigative function. They are issues, no doubt, of critical concern to Chrystalle's family, but also to the broader public. They are essentially matters of public importance rather than issues related to the investigation of the matters within the scope of the coroner's function arising from Chrystalle's death. 76 The existing reports also leave unanswered any attribution of responsibility or potential liability. As much as this may be a source of distress for Chrystalle's family, it is well established that such matters are not within the scope of an inquest. 77 I also have regard to the fact that the Coroner herself undertook a thorough investigative process and does not consider that an inquest is warranted. The statutory power expressly permits the court to take a view contrary to that of the coroner. It follows that the Coroner's view cannot be determinative. At the same time, it is not inappropriate in these circumstances to have regard to the view of the statutory officer -- 26 of 27 -- [2026] WASC 222 SOLOMON J Page 27 who is charged with, and has extensive experience with, the relevant considerations. Conclusion 78 For the reasons set out above, I do not consider it would be appropriate to exercise the statutory power to order an inquest. The request must therefore be declined. I certify that the preceding paragraph(s) comprise the reasons for decision of the Supreme Court of Western Australia. MS Associate to the Hon Justice Solomon 4 JUNE 2026 -- 27 of 27 --