Coronial
QLDhospital

Mr R - Non-inquest findings

Deceased

Mr R

Demographics

63y, male

Coroner

Clements

Date of death

2014-07-11

Finding date

2017-09-07

Cause of death

Multiple injuries due to fall from height

AI-generated summary

A 63-year-old man with Parkinson's disease died by suicide three days after discharge from hospital following reimplantation of a Deep Brain Stimulation (DBS) device. His initial DBS surgery in 2013 was successful, but device infection necessitated removal and reinsertion in 2014. Post-operatively, he experienced severe pain, mood disturbance with suicidal ideation, and adjustment difficulties. Although psychiatric assessment documented suicidal thoughts during admission, the treating team considered him psychiatrically fit for discharge to family care with outpatient follow-up arranged. Key clinical lessons include: the need for pre-operative psychiatric assessment to establish baseline functioning; careful monitoring for mood changes and pain control post-DBS; consideration of additive psychotropic medication when mood symptoms emerge; and recognition that suicide risk can be masked in methodical, obsessional patients. The coroner found the discharge decision appropriate based on expert review, but highlighted that suicide after DBS is multifactorial, involving device effects, pain, personality factors, and psychosocial stressors.

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

Specialties

neurosurgeryneurologypsychiatry

Error types

systemcommunication

Drugs involved

citalopramquetiapineclonazepamdopaminergic agentsrasagiline

Clinical conditions

Parkinson's diseasemajor depressive disorderpost-operative mood disturbancedysesthesia with paindevice infection

Procedures

deep brain stimulation (dbs) implantationDBS device reimplantationneurosurgery for DBS lead placement

Contributing factors

  • Post-operative DBS complications (device infection requiring reinsertion)
  • Inadequate pain control post-reimplantation
  • Mood disturbance and suicidal ideation in post-operative period
  • Lack of pre-operative psychiatric assessment
  • Possible DBS stimulation-related mood effects
  • Personal stressors including marital breakdown, financial difficulties, and uncertain living arrangements
  • Personality factors (obsessional, need for control)
  • Incomplete return to pre-morbid functioning after device reinsertion

Coroner's recommendations

  1. Pre-operative psychiatric assessment should be implemented for all DBS candidates to establish baseline psychiatric functioning and identify pre-existing psychiatric illness
  2. Clear documentation and communication to patients about post-DBS mood change risks, including suicide
  3. Enhanced monitoring for post-operative mood disturbance and pain control
  4. Implementation of formal discharge checklists for DBS patients ensuring emergency protocols, follow-up arrangements, and family supervision are documented
  5. Multidisciplinary discharge approval involving neurologist, neurosurgeon, neuropsychiatrist, and nursing staff
  6. Scheduled post-operative psychiatric follow-up within three months of discharge
  7. Clear emergency contact protocols and accessibility for patients experiencing post-operative complications
Full text
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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.

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