Inquest into the death of Zhong Liu

Contributing factors

• Arrhythmogenic cardiomyopathy (undetected inherited heart condition)
• Overdose of doxepin (taken 300mg+ daily, prescribed maximum 50mg)
• Overdose of venlafaxine at toxic levels
• Interaction between doxepin and venlafaxine causing cardiac arrhythmias
• High agitation and psychotic state increasing cardiac arrhythmia risk
• Physiological stress from physical restraint
• Communication breakdown regarding prescribed medication dosages
• Medication miscommunication between psychiatrist Dr Y. and patient regarding quetiapine vs doxepin dosing limits
• Patient's persistent self-medication escalation of prescribed drugs
• Multiple prescribers unaware of full medication history

Coroner's recommendations

1. NSW Real Time Prescription Monitoring scheme implementation (which coroner noted was scheduled to commence July 2021) to reduce medication overuse harms
2. Psychiatrists should arrange in-person interpreters for all pharmacological advice discussions with non-English speakers, particularly regarding medication dosing
3. Clinicians prescribing doxepin and venlafaxine in combination should ensure explicit patient understanding of dosages and obtain baseline ECG with cardiac monitoring
4. When patients present with toxic levels of medications in combination, psychiatrists should arrange urgent emergency department assessment for ECG and cardiac toxicity monitoring
5. Mental health case managers should escalate complex or unusual clinical situations to team leaders or senior clinicians for supervision and discussion
6. Case managers should consult with family members separately regarding safety planning when patients refuse voluntary hospitalization despite clinical deterioration