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Coroner's Finding: USHER Peter Michael

Deceased

Peter Michael Usher

Demographics

56y, male

Date of death

2018-11-14

Finding date

2020-10-12

Cause of death

hypoxic ischaemic encephalopathy following insulin and benzodiazepine overdose

AI-generated summary

A 56-year-old man with depression, known to close friends but not formally disclosed to healthcare providers, deliberately ingested temazepam tablets accumulated over time and insulin stolen from his mother on 10-11 November 2018. He was found unconscious in cardiac arrest with severe hypoglycaemia. Despite paramedic resuscitation and hospital treatment including intubation, he sustained global cerebral hypoxia and died four days later. He had been placed on an Inpatient Treatment Order prior to death. The coroner found no concerns with his care or custody. Clinical lessons include the importance of mental health screening in general practice, the risks of benzodiazepine accumulation, and recognition that depression may be concealed from healthcare providers despite being known to close contacts.

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

Specialties

anaesthesiapsychiatrygeneral practiceemergency medicineintensive care

Drugs involved

temazepaminsulinbenzodiazepinescocaine

Clinical conditions

depressionhypoglycaemiacardiac arresthypoxic ischaemic encephalopathyglobal cerebral hypoxiapulseless electrical activityright basal pneumonia

Procedures

intubationcardiopulmonary resuscitationdefibrillationsupraglottic airway insertionCT imaging

Contributing factors

  • deliberate overdose of temazepam and insulin
  • severe hypoglycaemia resulting in cardiac arrest
  • global cerebral hypoxia from prolonged cardiac arrest
  • undiagnosed or undisclosed depression
  • accumulation of benzodiazepines over time
  • access to mother's insulin without knowledge or control
Full text

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