Coroner's Court of Western Australia

Inquest into the Death of Pamela Edith ASHLEY

Inquest into the Death of Pamela Edith ASHLEY

Delivered on :22 May 2019

Delivered at : Perth

Finding of :Deputy State Coroner Vicker

Recommendations :Yes


I recommend the provision of mental health observation units attached to EDs, ICUs, HDUs in all hospitals which also have mental health facilities to allow appropriate transition of mental health patients, with high clinical risk factors for sudden deaths, from acute areas to general mental health facilities.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased at the time of her death was an involuntary patient at the Armadale Kelmscott District Memorial Hospital. She was 64 years of age.

The deceased had a medical history of well controlled diabetes mellitus, high cholesterol and bilateral leg swelling, apparently without cardiac cause, obesity and obstructive sleep apnoea. She also had a long history of bipolar affective disorder (BPAD).

On the evening of 2 February 2016 the deceased arrived at the emergency department of the Armadale Kelmscott District Memorial Hospital by ambulance due to her deteriorating mental health. She was assessed as requiring admission to an acute secure ward which was not immediately available. The deceased remained in the emergency department overnight. The next morning the deceased was still agitated and distressed and there were fears for both her safety and possibly others due to her very distressed behaviour. It was decided to move the deceased to an older adult mental health ward, which was secure, in an attempt to provide her with a more therapeutic environment.

In the days preceding the deceased’s admission to hospital she was sleep deprived and not drinking or eating adequately, while stressed over her dissatisfaction with the outcome of their recent move and her perceived inability to make things neat and tidy. This had continued for a number of days and would have depleted her ability to compensate for ongoing stressors to her system. Despite sedation in the emergency department which provided her some relief by way of sleep, the deceased remained resistant to intervention on the ward and a decision was made to her involuntary status and provided her with IM medication. This required the combined efforts of all nursing staff available on the ward in the presence of a medical registrar.

While close physical observations were not practical or safe on the ward for someone with the deceased’s presentation the deceased was visually observed until it was considered she was asleep and physical observations could be safely conducted. The deceased was found to be unresponsive and a medical emergency was called. The MET arrived and commenced aggressive resuscitation, unsuccessfully.

Expert evidence was heard in an attempt to clarify contributors to the deceased’s death. Overall it was considered toxicology did not contribute to her death, there being almost no sedating drugs in her system at the time of her death. A respiratory physician did not believe hypoventilation had contributed to the death due to the deceased’s biochemistry at the time of her arrest, but did consider her sleep apnoea predisposed her to sudden cardiac death. This related to all the physiological factors surrounding the deceased’s presentation leading up to her death.

The Deputy State Coroner was satisfied the deceased died as a result of a fatal cardiac arrhythmia in a lady with obstructive sleep apnoea, obesity and suffering an acute psychotic episode to the extent sedation was necessary in an attempt to reduce her level of agitation.

The Deputy State Coroner made a recommendation relating to clinical and physical risk factors in highly aroused mental health patients and a need for acute care units to deal with these patients when transitioning from acute medical care units to less specialised mental health units.

Catch Words : Sleep Apnoea : Observations : Involuntary Patients : Mental Health Units: Natural Causes.

Last updated: 7-Oct-2019

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