Inquest into the death of Sunjay Chandra

AI-generated summary

A 25-year-old man with schizophrenia died by suicide while on a Community Management Order following discharge from psychiatric hospital. He had been effectively stabilized on clozapine for years, but in late 2001 requested dose reduction due to side effects including sexual dysfunction. Following reduction, his condition deteriorated markedly over several months despite parental concerns. His parents provided detailed observations of psychotic symptoms including auditory hallucinations, disorganized behavior, and poor hygiene, but treating clinicians did not arrange earlier intervention despite multiple parental communications. He was admitted involuntarily in May 2002 in a catatonic state. After October 2002 readmission, alternative medications (amisulpride with carbamazepine) were trialed but achieved suboptimal symptom control compared to clozapine. He was discharged on 18 December 2002 with residual psychotic symptoms while denying mental illness. Toxicology showed sub-therapeutic drug levels, suggesting non-compliance. The coroner identified failures in weighting parental observations, unclear clozapine protocols regarding involuntary administration, and case manager workload concerns, but concluded the clinical decisions were reasonable given available options.

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