Coronial
NSWhospital

Inquest into death of Dane LOCKWOOD

Deceased

Dane Oliver Lockwood

Demographics

33y, male

Date of death

2019-08-19

Finding date

2022-10-28

Cause of death

methylamphetamine toxicity; antecedent causes being the physiological effects of the restraint and resistance to restraint

AI-generated summary

A 33-year-old man with methamphetamine addiction and possible schizophrenia attended the ED seeking help while acutely intoxicated, psychotic and sleep-deprived. After initially agreeing to medication, he attempted to leave and was involuntarily detained. During attempted restraint by security, paramedics and police over 20 minutes, he remained highly resistant. The coroner found the medical management appropriate given the chaotic environment and limited resources. However, systemic failures in ED design and drug addiction services contributed to his death. The coroner noted that physical restraint in an uncontrolled waiting room environment, combined with acute methylamphetamine toxicity and the physiological stress of prolonged struggle, led to cardiac arrest. The case highlights need for dedicated low-stimulus assessment units for behavioural disturbance and drug-affected patients.

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

Specialties

emergency medicinepsychiatrytoxicologyaddiction medicine

Error types

systemdelay

Drugs involved

methamphetaminediazepamolanzapinedroperidol

Clinical conditions

methamphetamine toxicityacute psychosisacute behavioural disturbancepossible schizophreniamethamphetamine-induced psychosiscardiac arrestasystole

Procedures

physical restraintintramuscular injectionintravenous accessmask applicationcardiopulmonary resuscitationadvanced cardiac life support

Contributing factors

  • acute methamphetamine intoxication
  • sleep deprivation for several days
  • acute psychosis with visual and auditory hallucinations
  • possible schizophrenia
  • non-compliance with antipsychotic medication
  • severe behavioural disturbance
  • prolonged physical restraint in uncontrolled environment
  • systemic failure in emergency department design
  • inadequate resources for managing acute behavioural disturbance
  • lack of dedicated low-stimulus assessment area accessible without public areas

Coroner's recommendations

  1. Send findings to the Minister for Health regarding systemic improvements needed for patients seeking help with serious drug addiction
  2. Progress the Emergency Department Assessment Unit (EDAU) at Prince of Wales Hospital, adapting the Royal Melbourne Hospital Behavioural Assessment Unit model and St Vincent's PANDA model, featuring low-stimulus environment, passive safety systems, time-delayed egress prevention, and multidisciplinary care to reduce need for restraint
  3. Improve physical design of emergency departments to provide safe assessment areas separated from main ED and public waiting areas
  4. Consider ante mortem blood results to improve assessment of true toxicity levels in suspected drug intoxication cases
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