Coroner's Finding: SHIN Jeong
Deceased
Jeong Shin
Demographics
35y, female
Date of death
2007-04-17
Finding date
2010-03-11
Cause of death
pulmonary thrombo-emboli
AI-generated summary
A 35-year-old woman with treatment-resistant schizophrenia detained under Mental Health Act died from pulmonary thromboembolism while an inpatient in a psychiatric ward. In the final days, she reported leg pain and possible chest pain but was combative and uncooperative with examination, complicating assessment. Clinical staff arranged investigations and interpreter assistance for the following day. When found collapsed, prolonged resuscitation was attempted but proved unsuccessful. The coroner found her detention lawful and appropriate, and her medical management reasonable. Notably, no deep vein thrombosis source was identified at autopsy, the cause of PE remained unknown, and earlier escalation probably would not have changed outcome. The case highlights challenges in assessing acutely unwell psychiatric patients with communication difficulties and limited cooperation who present with vague somatic symptoms.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Depo Provera contraceptive use (theoretical risk, not confirmed as causative)
- unknown source of thrombo-emboli
- possible leg injury/bruising
- patient uncooperativeness with examination
- communication difficulties (language barrier)
- delayed recognition of severity of presentation
Coroner's recommendations
- Training and protocols be implemented where SA Ambulance Service is called immediately in circumstances where a patient is located without a pulse (recommendation made by investigating police officer; coroner recommended this be considered by Chief Executive of Department of Health, noting it lacks universal medical practice support in hospital settings where patient is otherwise conscious and responsive)
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