Coroner's Finding: COCKBURN Michael Philip
Deceased
Michael Philip Cockburn
Demographics
40y, male
Date of death
2002-12-25
Finding date
2007-06-29
Cause of death
respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)
AI-generated summary
Michael Cockburn, a 40-year-old man with treatment-resistant schizophrenia and documented severe adverse reactions to antipsychotic medications, was admitted to Royal Adelaide Hospital from psychiatric detention for anaemia requiring blood transfusion. He became agitated during transfusion. An inexperienced intern prescribed haloperidol 10mg IM and clonazepam 2mg IM without reviewing available documentation explicitly warning against antipsychotics. Additionally, he received excessive clozapine (400mg instead of 175mg) due to a medication chart mix-up. Approximately one hour later he suffered cardiorespiratory arrest and subsequently died from ARDS. The coroner found sedation from multiple CNS depressants combined with his comorbidities (chronic obstructive airways disease, morbid obesity, undiagnosed coronary artery disease) likely triggered collapse. Critical lessons: junior doctors must consult senior staff and thoroughly review medication alerts before prescribing psychotropic drugs in complex psychiatric patients; medication chart verification systems must prevent substitutions; restraint situations warrant registrar involvement.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- cardiorespiratory arrest on 14 December 2002 preceding ARDS development
- sedation from haloperidol and clonazepam administration
- excessive clozapine dose (400mg instead of 175mg) due to medication chart mix-up
- chronic obstructive airways disease with compromised lung function
- morbid obesity (145kg, 187cm)
- undiagnosed severe coronary artery disease with myocardial ischaemia
- anaemia
- possible minor pulmonary embolism
- subsequent bronchopneumonia and infection in ICU
- failure to review medication alert documentation before prescribing antipsychotics
Coroner's recommendations
- RAH to formally remind all nursing and medical staff to carefully examine patient files for medication alerts before administering drugs known to produce adverse side effects
- RAH to consider implementing measures ensuring medical practitioners at registrar level or above are preferentially called to restraint situations or made aware and tasked to provide advice to junior practitioners
- RAH to formally impress upon nursing and medical staff, especially interns, to consult more senior staff if in doubt about medication appropriateness
- Glenside to implement measures preventing substitution of one patient's documentation for another's
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