Inquest into the Death of Christopher John DEBNAM

Inquest into the Death of Christopher John DEBNAM

Delivered on :22 May 2019

Delivered at : Perth

Finding of : Deputy State Coroner Vicker

Recommendations :Yes

Recommendation 1

Compliance with proper discharge planning between all facilities dealing with patients with mental health issues.

Recommendation 2

Emphasis on clinical medical health issues for those suffering mental health conditions while in the community so risk factors when inpatients are properly appreciated.

Recommendation 3

Consideration and documentation of the benefits or otherwise of oxymetric observations of sedated mental health patients with other risk factors for respiratory arrest, especially sleep apnoea where visual observations may not detect hypoventilation.

Recommendation 4

More availability of appropriate acute facilities for highly aroused mental health patients at times of essential sedation.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased at the time of his death was pending an involuntary patient assessment at Graylands in a secure ward having been admitted late on 20 November 2014 due to a relapse of his mental health issues. He was 40 years of age.

The deceased was an obese male originally diagnosed with chronic paranoid schizophrenia later refined to suffering BPAD with psychotic features, who was prone to a high degree of arousal when he became unwell. Past history indicated he could become very aggressive and violent when unwell. He had been released from Graylands on 12 November 2014 without including his community mental health team in discharge planning. On 20 November 2014 the deceased, who had been recently discharged as a voluntary patient into the care of his family, was exhibiting elevated levels of agitation. The deceased’s parents while wanting him home were unable to care for him and asked for assistance. The deceased was admitted to Graylands Hospital pending assessment and provided with a bed with a primary focus being a reduction in his agitation for both his own and other persons’ safety. He was reviewed and provided with medication he had tolerated well over his prior two months while at Graylands.

Observations of the deceased were within normal levels apart from a slightly elevated blood pressure. Due to his level of agitation a comprehensive medical assessment was not possible. There was nothing from the assessment for the deceased on his admission, nor his admission to the ward which indicated elevated monitoring or observations were necessary. His history recorded he had sleep apnoea and was obese. There was nothing recently to indicate he needed more frequent monitoring than the usual respirations hourly.

The Deputy State Coroner accepted it was a priority to reduce the deceased’s level of agitation, which was usually successfully done via sedation, and that due to the same sedation having been used successfully in the prior two months, it was not considered the deceased was at risk of respiratory arrest and so warranted transfer to an acute clinical setting. The Deputy State Coroner was satisfied the deceased died as the result of his combined undiagnosed cardiomyopathy and reported obstructive sleep apnoea following a cardiorespiratory arrest. There was no evidence the sedation with which the deceased been provided on the evening of the 20 November 2014 was still providing sedation on the morning of 21 November 2014. Rather it was considered possible developing hypoventilation caused respiratory depression then arrest on the background of his naturally occurring cardiac disease, sleep apnoea developing pneumonia and obesity. The Deputy State Coroner found death occurred by way of Natural Causes.

The Deputy State Coroner made four recommendations ensuring appropriate clinical investigation of patients with physical conditions which would predict a risk with the necessary treatment when highly unwell and the development of more acute care units for highly aroused mental health patients with high clinical risk factors for cardio respiratory arrest.

Catch Words : Sleep Apnoea : Clinical and Physical Assessments : Involuntary Patients : Mental Health Management : Natural Causes.

Last updated: 4-Jun-2019

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