Coroner's Finding: Butler Mark Andrew
Deceased
Mark Andrew Butler
Demographics
49y, male
Date of death
2009-07-04
Finding date
2012-11-15
Cause of death
pneumonia, hypoxic brain injury and cardiac arrest
AI-generated summary
49-year-old male with chronic cannabis dependence and depression developed post-surgical delirium following emergency anterior resection for perforated diverticulum. He became acutely agitated and paranoid, was detained under mental health order, and shackled to bed. After freeing himself and being restrained by security staff, he suffered cardiac arrest with hypoxic brain injury and died. Contributing factors included failure to recognise cannabis withdrawal contributing to delirium, use of anticholinergic olanzapine potentially worsening confusion, and shackling potentially worsening paranoia. Expert opinion noted clinical errors occurred but no clear causal link to fatal outcome. Death attributed to pneumonia, hypoxic brain injury and cardiac arrest on background of coronary atherosclerosis and ischaemic heart disease.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- post-surgical, post-anaesthetic delirium
- cannabis withdrawal syndrome
- chronic cannabis dependence
- failure to diagnose relationship between delirium and cannabis dependence
- use of intramuscular olanzapine with anticholinergic effects potentially worsening confusion
- shackling potentially worsening paranoia
- underlying coronary atherosclerosis and ischaemic heart disease
- cardiac arrest during restraint
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