A coronial inquest last week heard Bradley Buswell was taken off his regular antipsychotic medication eight months before his death due to a nationwide shortage.<\/p>\n
Mr Buswell, 42, died suddenly in March 2025 while on a psychiatric community treatment order.<\/p>\n
He was found with 52 times the normal amount of his replacement medication in his system.<\/p>\n
“The fact that he was able to obtain, store, and consume such quantities of medication without the knowledge of those caring for him raises significant concerns,” the family said in a letter to the inquest.<\/p>\n
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In a statement, WA Country Health Service (WACHS) acting executive director Jeff Calver expressed deep sorrow for the family’s loss, but said he understood there were no shortcomings in the care provided.<\/p>\n
“While I’m limited in what I can say due to the ongoing coronial process, mental health challenges are complex, and we know a patient’s condition can change rapidly,” he said.<\/p>\n
His family told the ABC that Mr Buswell would be remembered for his gentle nature, his love for family and friends, the outdoors and the Fremantle Dockers rather than his illness.<\/p>\n
The coroner will hand down his findings by September.<\/p>\n
‘Treatment-resistant’ mental illness<\/p>\n
In 2021, Mr Buswell began calling his friends and family to say goodbye and sell off his belongings.<\/p>\n
The inquest heard he believed he was going to die from a serious illness.<\/p>\n
When his family discovered he had been suffering from schizophrenia, his years of sleepless nights and preoccupation with his health began to make sense.<\/p>\n
His friends and family grew worried, and he was admitted to Bunbury Regional Hospital’s psychiatric ward under WA’s Mental Health Act.<\/p>\n
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<\/p>\nBradley Buswell struggled with conditions when admitted to Bunbury Hospital. (ABC South West: Anthony Pancia)<\/p>\n
“[The ward] was often chaotic, overstimulating, and populated by patients in acute distress,” family members told the coroner.<\/p>\n
“For Bradley, who was gentle, quiet, and already overwhelmed by his symptoms, these environments were traumatising rather than therapeutic.”<\/p><\/blockquote>\n
Mr Buswell’s health had deteriorated further on the ward, and he was eventually released on a community treatment order.<\/p>\n
The order required him to live with his grandmother, regularly attend his appointments and follow his treatment plan.<\/p>\n
His treating psychiatrist, Daniel de Klerk, commenced him on intramuscular olanzapine, an antipsychotic injected monthly.<\/p>\n
“The choice to administer intramuscularly was a result of uncertainty about whether he was going to take oral medications,” Dr de Klerk told the inquest.<\/p>\n
Despite his schizophrenia being labelled as “treatment-resistant”, the injected olanzapine was working well to manage his symptoms.<\/p>\n
“His symptoms never completely resolved but he became much less distressed,”<\/p><\/blockquote>\n
Dr de Klerk said.Nationwide shortages<\/p>\n
In 2024, intramuscular olanzapine became abruptly unavailable in Australia.<\/p>\n
The medication had run out of contract, with the overseas manufacturer not making it anymore.<\/p>\n
Mr Buswell was given oral olanzapine instead, but his mental health suffered as a result, the inquest was told.<\/p>\n
“It was not very long before we had reports from the family that he was saying goodbye again,”<\/p><\/blockquote>\n
Dr de Klerk said.<\/p>\n
Mr Buswell was then prescribed a different antipsychotic, also delivered via injection, but it was not as effective.<\/p>\n
Dr de Klerk told the inquest it was to ensure his treating team knew he was taking “something”.<\/p>\n
Mr Buswell was “intermittently” taking his oral olanzapine, admitting multiple times to his treating team that he was not taking the pills for days.<\/p>\n
“It doesn’t work from the bedside table, unfortunately, you have to swallow the tablets,” Dr de Klerk said.<\/p>\n
At his final review, days before his death, he admitted to not taking his olanzapine.<\/p>\n
Days later, Mr Buswell was found dead in his room with 52 times the prescribed amount of olanzapine in his system.<\/p>\n
![\"A](\"https:\/\/www.europesays.com\/ie\/wp-content\/uploads\/2026\/07\/47482f62e4d09d14cfcfc310d8a873d6.jpeg\")
<\/p>\nBunbury Regional Hospital is undergoing a major, multi-year redevelopment that includes more mental health beds. (ABC South West WA: Bridget McArthur)<\/p>\n
Family’s ‘significant concerns’<\/p>\n
Mr Buswell’s family said they were not told he had been prescribed the oral olanzapine, only that he was being injected with a different drug monthly.<\/p>\n
“Had we been informed of the medications he was prescribed, we would have been able to monitor his access, support him in taking them safely, and potentially prevent the accidental overdose that contributed to his death,” the family told the inquest.<\/p>\n
The family told the ABC they believed he was failed by the system, not one individual, and thanked his treating team for their thoughtful care.<\/p>\n
Those closest to Mr Buswell believe his death was accidental, not intentional.<\/p>\n
“For a man so terrified of death, the idea that he would deliberately take his own life makes no sense to us,”<\/p><\/blockquote>\n
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