Deceased
Roland Ashbolt
Demographics
39y, male
Coroner
Decision ofDeputy State Coroner Lee
Date of death
2022-06-28
Finding date
2025-06-12
Cause of death
clozapine toxicity
AI-generated summary
Roland Ashbolt, a 39-year-old man remanded in custody with schizophrenia, died from clozapine toxicity. He had been prescribed clozapine (400mg daily) from January 2022 with good clinical response and therapeutic levels. On 28 June 2022, he was found unresponsive in his cell at Long Bay Correctional Centre Mental Health Unit. Post-mortem analysis showed clozapine at 4.6 mg/L (therapeutic range 0.35-0.6 mg/L), indicating one or more overdoses. Expert evidence established the clozapine level was not artifactual despite eight-day post-mortem interval. The prescription of clozapine was clinically appropriate given treatment-resistant schizophrenia and previous positive response. Administration protocols including supervised medication and oral cavity checks were appropriate. Regular cell searches and nursing checks were conducted. No evidence suggested additional preventive measures were strongly indicated. Death was classified as misadventure due to unintentional overdose.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
Clinical conditions
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