The family of a man with schizophrenia who died in a state hospital say his death raises “serious concerns” about his treatment in Western Australia’s mental health system.
Warning: This article contains references to mental health.
A coronial inquest last week found Bradley Buswell had to stop taking his regular antipsychotic medication eight months before his death due to a nationwide shortage of the drug.
Mr Buswell, 42, died suddenly in March 2025 while being treated in a mental health facility.
52 times the normal amount of replacement medication was found in his system.
“The fact that he was able to obtain, store and consume so many medications without the knowledge of those caring for him is of grave concern,” the family said in a letter to investigators.
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In a statement, Washington State Health Services (WACHS) Acting Executive Director Jeff Culver expressed deep sadness for the family’s loss, but said he understands there were no deficiencies in the care provided.
“While I am limited in what I can say due to the ongoing coronial process, mental health issues are complex and we know a patient’s condition can change quickly,” he said.
His family told the ABC Mr Buswell will be remembered for his gentle nature, love of family and friends, the outdoors and Fremantle dockers, rather than his illness.
The coroner will announce his findings by September.
Mental illness “resistant to treatment”
In 2021, Buswell began calling his friends and family to say goodbye and sell his belongings.
The inquest heard he believed he would die from a serious illness.
When his family discovered he suffered from schizophrenia, his years of sleepless nights and concern for his health began to make sense.
His friends and family became concerned and he was admitted to the psychiatric ward at Bunbury Regional Hospital under the WA Mental Health Act.
Bradley Buswell was battling serious illness when he was admitted to Bunbury Hospital. (ABC South West: Anthony Pancia)
“(The ward) was often chaotic, overly agitated and populated by patients in acute illness,” family members told the coroner.
“For Bradley, who was gentle, quiet and already overwhelmed by his symptoms, this environment was more traumatic than therapeutic.”
Mr Buswell’s health deteriorated further on the ward and he was eventually released into compulsory treatment.
The order required him to live with his grandmother, attend regular appointments and follow a treatment plan.
His treating psychiatrist, Daniel de Klerk, prescribed intramuscular olanzapine, an antipsychotic administered monthly.
“The decision to administer intramuscular injection was a result of uncertainty about whether he would take oral medication,” Dr de Klerk told the inquest.
Although his schizophrenia was described as “treatment-resistant”, the olanzapine administered managed his symptoms well.
“His symptoms never completely went away, but he became much less upset.”
– said Dr. de Klerk.
Nationwide deficit
In 2024, intramuscular olanzapine suddenly became unavailable in Australia.
The contract for the drug has expired and the foreign manufacturer is no longer producing it.
Instead, Buswell was given oral olanzapine, but as a result his mental health deteriorated, the inquest was told.
“We soon received messages from the family that he was saying goodbye again,”
– said Dr. de Klerk.
Buswell was then prescribed another antipsychotic, also given by injection, but it was not as effective.
Dr de Klerk told the inquest this was to ensure his treatment team knew he was taking “something”.
Mr Buswell took oral olanzapine “intermittently”, repeatedly admitting to his treatment team that he had not taken his pills for several days.
“Unfortunately, it doesn’t work from the bedside table, you have to swallow the pills,” Dr de Klerk said.
At his last examination, a few days before his death, he admitted that he had not taken olanzapine.
A few days later, Buswell was found dead in his room with 52 times the prescribed amount of olanzapine in his system.
Bunbury Regional Hospital is undergoing a major multi-year refurbishment to add more mental health beds. (ABC South West WA: Bridget McArthur)
“Significant problems” of the family
Mr Buswell’s family said they were not told he was prescribed oral olanzapine, only that he was given a different drug every month.
“Had we been informed of the medications he was prescribed, we could have controlled his access, supported him in taking them safely and potentially prevented the accidental overdose that contributed to his death,” the family told the inquest.
The family told the ABC they believe he was let down by the system, not one person, and thanked his treatment team for their thoughtful care.
Those close to Buswell believe his death was accidental and not intentional.
“For a person who is so afraid of death, the idea that he would intentionally commit suicide makes no sense,”
the family said.