Coronial
NSWhospital

Inquest into the death of Irene Charlish

Deceased

Irene Charlish

Demographics

68y, female

Coroner

Decision ofDeputy State Coroner Kennedy

Date of death

2017-06-11

Finding date

2023-03-03

Cause of death

Complications of a fall with contributing factors of respiratory failure, respiratory disease, coronary artery disease and acute kidney disease, further complicated by underlying schizoaffective disorder

AI-generated summary

Irene Charlish, a 68-year-old woman with longstanding schizoaffective disorder and multiple comorbidities, fell at her residential facility on 6 June 2017, sustaining a pneumothorax and rib fracture. She was admitted to Ryde Hospital where she refused treatment, became aggressive, and resisted hydration and medication administration. Despite appropriate medical care, she died on 11 June 2017. Expert toxicology review confirmed clozapine levels reflected post-mortem redistribution, not overdose. The coroner found her death resulted from natural causes (likely respiratory failure, cardiac event, or pulmonary embolism) compounded by her complex medical and psychiatric conditions. Care was deemed appropriate; no preventable errors were identified. The case highlights challenges managing acutely unwell psychiatric patients refusing care.

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

Specialties

emergency medicinepsychiatryrespiratory medicinegeneral medicine

Drugs involved

clozapinesodium valproatepravastatinperindoprilmetforminrabeprazolevitamin dparacetamoloxycodonemidazolamdiazepam

Clinical conditions

schizoaffective disorderpneumothoraxrib fracturerespiratory failurecoronary artery diseaseacute kidney diseasechronic renal impairmenttype 2 diabetesasthmacolon adenocarcinomaobesityosteoarthritisiron deficiency anaemia

Procedures

CT scan of chestintravenous cannula insertion

Contributing factors

  • Fall with pneumothorax and rib fracture
  • Respiratory failure
  • Respiratory disease
  • Coronary artery disease
  • Acute kidney disease
  • Chronic renal impairment
  • Patient refusal of treatment and hydration
  • Complex psychiatric presentation limiting cooperation
  • Multiple comorbidities

Coroner's recommendations

  1. No additional recommendations arise from this death. Changes already implemented at Ryde Hospital include: launch of e-Meds system (December 2017) with electronic alerts for venous thromboembolism prevention; improved awareness of Specialist Psychiatry Consultation Review program through updated Clinical Nurse Consultant role; and updated delirium screening process using Abbreviated Mental Test Score (AMTS).
Full text

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.