Shayni Nelson has provided information regarding a coronial inquest concerning Bradley Buswell, a 42-year-old man from Western Australia who struggled with schizophrenia and passed away while under state care. His death occurred eight months after he was taken off his regular antipsychotic medication due to a nationwide shortage, prompting his family to voice their concerns about the treatment he received within the state’s mental health framework.
The coroner is expected to deliver findings by September. The inquest, held last week, revealed that Mr. Buswell was removed from his antipsychotic medication eight months prior to his death, which took place in March 2025 while he was subject to a psychiatric community treatment order. He was discovered with an alarming concentration of 52 times the usual dosage of his replacement medication in his system.
In a letter addressing the inquest, Mr. Buswell’s family expressed significant worry over the fact that he had managed to access, store, and consume such large quantities of medication without the awareness of his caregivers.
Jeff Calver, the acting executive director of WA Country Health Service (WACHS), expressed his condolences to the family while asserting that he believed there were no failings in the care provided to Mr. Buswell. He noted the complexities of mental health conditions and how a patient’s state can change swiftly, although he acknowledged that his comments were limited due to the ongoing investigation.
The family shared with ABC that they would remember Mr. Buswell for his gentle disposition, his affection for family and friends, his appreciation for nature, and his loyalty to the Fremantle Dockers, rather than focusing solely on his illness.
In 2021, Mr. Buswell began reaching out to friends and family to say his farewells and liquidate his possessions, indicating he believed he was facing a terminal illness. Upon learning about his schizophrenia, the family began to understand his prolonged sleepless nights and obsessive concerns about his health.
His loved ones grew increasingly alarmed, leading to his admission to the psychiatric ward at Bunbury Regional Hospital under WA’s Mental Health Act. Family members reported that the ward was often chaotic and overwhelming, which was particularly distressing for Mr. Buswell, whose gentle and reserved nature made such environments traumatic rather than therapeutic.
His condition worsened while hospitalized, and he was eventually discharged under a community treatment order that required him to reside with his grandmother and adhere to a treatment plan that included regular appointments. His psychiatrist, Dr. Daniel de Klerk, began administering intramuscular olanzapine, a monthly injection of an antipsychotic, due to uncertainties about Mr. Buswell’s adherence to oral medications.
Although Mr. Buswell’s schizophrenia was characterized as “treatment-resistant,” the monthly injections were effective in reducing his distress, though his symptoms never fully resolved. However, in 2024, intramuscular olanzapine became unavailable in Australia, leading to a switch to oral olanzapine, which adversely affected his mental health.
Dr. de Klerk noted that the family soon reported Mr. Buswell expressing farewell sentiments once again. After being prescribed a different injectable antipsychotic, it was evident that it was not as effective as the previous medication. Dr. de Klerk highlighted that it was important to ensure that Mr. Buswell was at least taking some form of medication.
Throughout his treatment, Mr. Buswell intermittently admitted to his care team that he had not been taking his oral olanzapine for several days. Dr. de Klerk emphasized that the medication would not be effective if not ingested. Just days before his passing, Mr. Buswell confessed during a review that he had not taken his prescribed medication.
Tragically, shortly after this admission, he was found deceased in his room, with an alarming concentration of olanzapine in his system.
Mr. Buswell’s family conveyed to the inquest that they were not informed about his prescription for oral olanzapine; they were only aware of the monthly injections he was receiving. They believe that had they been informed about the medications, they could have better monitored his access and possibly prevented the accidental overdose contributing to his death. The family expressed gratitude to the treatment team for their compassionate care but felt that the systemic failings were to blame, rather than any one individual.
Those who knew Mr. Buswell believe that his death was not a result of intentional action. They stated, “For a man so terrified of death, the notion that he would deliberately take his own life is incomprehensible to us.”
