Coroner's Finding: O'BRIEN Barbara Ann
Deceased
Barbara Ann O'Brien
Demographics
57y, female
Date of death
2001-12-12
Finding date
2005-08-30
Cause of death
right bronchopneumonia following hypoxic brain damage secondary to cardiac arrest
AI-generated summary
A 57-year-old woman with chronic schizophrenia and non-insulin dependent diabetes was admitted to a psychiatric ward after detention under the Mental Health Act. She was found in cardiac arrest on 8 December 2001 and suffered severe hypoxic brain injury, dying from bronchopneumonia. While hypoglycaemia was present (BSL 2.1-2.4 mmol/L) and has been criticised as inadequately monitored, expert evidence indicates the cardiac arrest was more likely caused by cardiac arrhythmia from antipsychotic medication (Clozapine, Lithium, Chlorpromazine) combined with underlying coronary artery disease, rather than hypoglycaemia itself. The deceased remained conscious despite low BSL levels. Direct admission to the psychiatric ward bypassing the Emergency Department, infrequent BSL testing, and lack of IV dextrose were identified as shortcomings, though expert opinion suggested these would unlikely have prevented the arrest.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- cardiac arrest of uncertain aetiology
- hypoxic brain injury from prolonged cardiac arrest
- antipsychotic medication (Clozapine, Lithium, Chlorpromazine)
- underlying coronary artery disease
- chronic and moderate hypoglycaemia
- inadequate monitoring of blood sugar levels
- direct admission to psychiatric ward bypassing Emergency Department
- infrequent blood sugar level testing
- lack of IV dextrose infusion
Full text
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