Cooper, Paul James - Non-inquest findings
Deceased
Paul James Cooper
Demographics
41y, male
Date of death
2015-08-25
Finding date
2016-02-05
Cause of death
Hanging
AI-generated summary
Paul Cooper, a 41-year-old man with bipolar disorder, died by hanging in August 2015, eleven days after psychiatric review. He had recently commenced Isotretinoin for severe acne, which coincided with development of paranoid delusions, suicidal ideation, and significant functional decline. Although initially assessed as low-risk and improved on antipsychotic therapy, critical gaps emerged: no discharge summary was sent to his GP, family were not contacted despite interstate/overseas residence, and when phone contact failed between 21-24 August, no alternative follow-up occurred. Toxicology revealed he was not taking prescribed Risperidone, unknown to the treating team. The case highlights importance of coordinated discharge planning, GP communication, regular risk reassessment after failed contact attempts, and awareness of Isotretinoin's potential psychiatric adverse effects.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Isotretinoin-associated psychiatric adverse effects (paranoid delusions, suicidal ideation)
- Lack of discharge summary to general practitioner
- No family contact despite interstate/overseas residence
- Failure to escalate when phone contact unsuccessful between 21-24 August
- Unknown non-compliance with Risperidone
- Limited follow-up frequency (only two contacts in August after hospital discharge)
Coroner's recommendations
- Importance of discharge summaries being forwarded to the treating general practitioner
- Importance of contact with family members where possible during treatment
- Implementation of systematic follow-up protocols when routine phone contact is unsuccessful
- Regular risk reassessment, particularly in early post-discharge period
Full text
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