Inquest into the death of Edward Haenga

Contributing factors

• morbid obesity with cardiomegaly
• concurrent multiple antipsychotic medications carrying QT prolongation risk
• high-dose escitalopram (30mg) combined with amisulpride, pericyazine, quetiapine, and methadone
• lack of ECG monitoring despite QT-prolonging medication regime
• inadequate metabolic monitoring participation
• liver dysfunction and Hepatitis C
• elevated postmortem drug concentrations (amisulpride and escitalopram)

Coroner's recommendations

1. To GEO: (a) adopt Justice Health Psychotropic Medications Guidelines 2017 and NSW Ministry of Health Metabolic Monitoring module as part of Junee's metabolic monitoring policy; (b) review Medication Administration Policy dated 21 April 2017 to ensure it accurately reflects Justice Health guideline provisions, particularly clauses 4.7.1 and 4.14.8
2. To Justice Health Director: revise the 2011 Metabolic Syndrome Resource to include (a) sufficient information and guidance regarding use and relevance of baseline and ongoing ECG testing as part of metabolic monitoring, and (b) cross-reference to recommended clinical timeframes for ongoing ECG testing in the 2017 Psychotropic Medications Guidelines, particularly for specific antipsychotic medications
3. To GEO Chief Executive, Justice Health Director, and CSNSW Commissioner: work collaboratively to provide targeted education and training through Justice Health nurse education consultants to GEO clinical staff regarding medication administration requirements per Justice Health Medication Guidelines 2017, particularly clauses 6.2.9 and 6.7.2