Robinson, Terence James
Deceased
Terence James Robinson
Demographics
54y, male
Coroner
Barnes
Date of death
2004-10-08
Finding date
2006-09-08
Cause of death
Global cerebral hypoxic injury due to or as a consequence of status epilepticus
AI-generated summary
Terence James Robinson, 54, died from status epilepticus causing global cerebral hypoxic injury after 16 days at Belmont Private Hospital. He was admitted following a violent altercation with police and attempted suicide. After emergency sedation with benzodiazepines and antipsychotics on 29 September, he developed profound sedation and neurological deterioration. Critical issues included: lack of daily psychiatric review in the Special Care Unit (he was not seen on day 3 post-sedation); delayed recognition of serious deterioration; and uncertainty about transfer timing to a medical facility. While drug therapy was not definitively shown to cause death, experts identified potential triggers including medication interactions, old brain lesion predisposing to seizures, and possible non-convulsive status epilepticus. The coroner recommended implementing a rapid tranquilisation policy and daily SCU reviews to prevent similar deaths.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- emergency rapid tranquilisation with benzodiazepines and antipsychotic medications on 29 September 2004
- old ischaemic brain lesion from 1999 CVA predisposing to seizures
- withdrawal or interaction of anticonvulsant medication (Sodium Valproate)
- lack of daily psychiatric review in Special Care Unit
- delayed recognition of serious neurological deterioration
- possible non-convulsive status epilepticus unrecognised prior to 6 October
- prolonged sedation obscuring neurological assessment
- delayed transfer to medical facility with appropriate investigation capability
Coroner's recommendations
- Development of a rapid tranquilisation policy at Belmont Private Hospital, potentially guided by Queensland Health statewide policy development
- Review of BPH policy to ensure daily psychiatric review of patients in the Special Care Unit (rather than six days per week)
- Consideration of when transfers to external medical facilities should be initiated, particularly for patients with significant physical deterioration and uncertain aetiology
Full text
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