SAhospital

Coroner's Finding: McLEOD Peter Malcholm

Deceased

Peter Malcholm McLeod

Demographics

28y, male

Date of death

2003-11-01

Finding date

2006-09-25

Cause of death

Acute Dopamine Imbalance Syndrome

AI-generated summary

A 28-year-old man with first-episode psychosis presented with command auditory hallucinations after a motor vehicle accident. An EEG ordered to exclude organic causes showed very abnormal findings suggestive of partial seizure focus. Despite this critical result, the psychiatric team did not urgently consult neurology before discharging him to a home-based treatment program. He received sodium valproate prophylactically without neurology input. When he deteriorated five days later, he was admitted to the ED where he spent five hours undergoing vague "physical clearance" rather than targeted neurological assessment despite known abnormal EEG and recent antipsychotic initiation. His Glasgow coma score collapsed from 13 to 5 during this period. He was transferred to ICU, intubated, and died. The cause was determined to be acute dopamine imbalance syndrome (possibly neuroleptic malignant syndrome or lethal catatonia). Key failures: no urgent neurology consultation after abnormal EEG; discharge to community without neurological assessment; unfocused ED evaluation with failure to recognise evolving neuroleptic malignant syndrome; delayed recognition of clinical deterioration.

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

Specialties

psychiatryneurologyemergency medicineintensive care

Error types

communicationdiagnosticdelaysystem

Drugs involved

risperidonesodium valproatepropofolmidazolam

Clinical conditions

first-episode psychosisschizophreniacommand auditory hallucinationsabnormal EEG with focal slow and sharp wave activitypartial seizure focusneuroleptic malignant syndromelethal catatoniaacute dopamine imbalance syndromecatatoniacerebral hypoxic injuryraised intracranial pressuretentorial herniation

Procedures

electroencephalographyCT scanMRI scanintubationmechanical ventilation

Contributing factors

Failure to urgently consult neurology after abnormal EEG report
Discharge to Hospital at Home program without neurological assessment
Prophylactic sodium valproate prescribed without neurology consultation
Unfocused physical examination in ED without targeted neurological assessment
Delayed recognition of neuroleptic malignant syndrome features
Failure to recognise clinical deterioration between 11:00am and 4:00pm on 29 October 2003
Collapse of Glasgow coma score from 13 to 5 without appropriate intervention
Lack of communication protocol between psychiatry and neurology departments
EEG report not brought to attention of treating team before discharge

Coroner's recommendations

The Royal Adelaide Hospital should re-emphasise the need for full and appropriate interaction between psychiatry and neurology departments in appropriate cases, emphasising the need for urgent neurological consultation after abnormal EEG reports in first-presentation psychosis cases
The Forensic Science Centre should identify in all toxicology reports the date and time at which the sample being tested was taken, and where toxicology tests are carried out as part of a coronial post-mortem examination, a report of test results must be provided to the State Coroner

Full text

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Source and disclaimer

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