Coroner's Court of Western Australia

Inquest into the Death of Jason James Sutherland MALLETT

Inquest into the Death of Jason James Sutherland MALLETT

Delivered on : 20 December 2019

Delivered at : Perth

Finding of : Coroner Linton

Recommendations : Yes

I recommend that the WA Department of Health give consideration to utilising pulse oximetry in mental health patients who have been agitated and required significant sedation, for a suitable period of observation, to ensure that any monitoring is capable of identifying where a patient is exhibiting a decrease in oxygen saturation that may indicate they are experiencing a cardiac event.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased at the time of his death was an involuntary patient under the Mental Health Act 2014. The deceased was being treated for mental health issues at Sir Charles Gairdner Hospital when he died as a result of a sudden disturbance of his heart’s normal beating rhythm on the background of significant pre-existing heart disease.

The inquest focussed primarily on the deceased’s medical treatment during his admission to Sir Charles Gairdner Hospital and to identify whether his heart disease should have been identified, and whether his monitoring was adequate.

On 24 February 2017 the deceased was admitted as a voluntary patient to the Sir Charles Gairdner Hospital Mental Unit. He was started on various medications to manage his illicit drug withdrawals and psychotic symptoms. He had a physical examination and an ECG was requested, which appeared normal.

On 27 February 2017 the deceased was made an involuntary patient after being reviewed. He was increasingly distressed, manic and significantly psychotic and needed to be in the locked part of the Mental Health Unit. The change from being a voluntary to involuntary patient was significant for the deceased because, as an involuntary patient, he was no longer able to go outside the ward to smoke. The deceased was a heavy chain smoker.

On 2 March 2017 the deceased rang his mother and complained that he could not have a cigarette and was going to die in hospital. The deceased was very agitated and abusive towards staff at this time. He was given medications to calm him, including intramuscular clonazepam. When he eventually agreed to take oral medications, the deceased was provided with a dose of quetiapine, chloral hydrate and Phenergan and was taken to his bedroom. He was encouraged to stay in his room to allow the medications to take effect. The deceased was then monitored by nursing staff. On the last observations, prior to handover, the deceased was found to be unresponsive. CRP was immediately commenced. A bedside ultrasound showed no cardiac activity.

The Coroner made one recommendation for additional measures be implemented for patients to have pulse oximetry in a psychiatric setting, where a patient is cooperative to its use. This would assist staff to monitor patients who have recently been agitated and then sedated.

The Coroner found the deceased’s medical care was of a generally high standard.

Catch Words : Physical Monitoring and Pulse Oximetry : Psychiatric Care : Cardiac Disease : Natural Causes

Last updated: 22-Mar-2020

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