Coronial
NSWmental health

Inquest into the death of Mark Richard GLEESON

Deceased

Mark Richard Gleeson

Demographics

39y, male

Date of death

2011-12-21

Finding date

2014-06-18

Cause of death

respiratory failure as a result of the interaction of prescribed medication and alcohol

AI-generated summary

Mark Richard Gleeson, 39, died from respiratory failure caused by the combined effect of prescribed antipsychotic/anxiolytic medications (olanzapine, quetiapine, clonazepam) and alcohol consumed within hours of discharge from Wollongong Hospital Mental Health Unit on 21 December 2011. He had been admitted voluntarily with command hallucinations and self-harm thoughts but was deemed competent to refuse proposed treatment and discharged at his insistence. He was dispensed a 7-day supply of medication as standard practice. The coroner found no evidence of intentional suicide, instead concluding accidental death from reckless medication consumption. Clinicians appropriately respected his autonomy as a voluntary patient and mental health legislative requirements, though family notification was limited by his explicit refusal and privacy legislation. No systemic failures were identified.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • consumption of lethal combination of antipsychotic and anxiolytic medications
  • alcohol consumption
  • drug interaction causing respiratory depression
  • history of reckless substance use
  • impulsive decision-making
  • personality disorder with impulsive traits
  • patient's refusal of family notification and alternative care options
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