Coroner's Finding: Adams, Michael Gerard
Deceased
Michael Gerard Adams
Demographics
62y, male
Date of death
2020-02-14
Finding date
2023-10-13
Cause of death
cardiac arrest complicating psychotic episode
AI-generated summary
Michael Adams, aged 62 with chronic treatment-resistant schizophrenia, died from cardiac arrest complicating psychotic episode at a supported residential facility. During escalating psychotic behaviour, paramedics applied a restraint blanket but failed to maintain continuous patient monitoring as required by policy. For approximately four minutes after police arrival, paramedics did not detect that Adams had deteriorated into cardiac arrest, delaying CPR initiation. Critical failures included: inadequate observation while restraining (no clinician maintained head-of-stretcher position), failure to apply supplemental oxygen despite visible cyanosis, and lack of awareness that psychiatric patients and antipsychotic medications increase sudden cardiac arrest risk. There was also a five-hour initial response delay (Priority 4 tasking not escalated appropriately). Clinical lessons: maintain constant observation during physical restraint of agitated patients; recognize sudden changes in behaviour as potentially indicating serious deterioration; appreciate the increased cardiac risk in psychiatric emergencies; apply policies requiring oxygen and head-end clinician positioning.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- pre-existing moderate coronary artery atherosclerosis
- physical exertion from agitated psychotic behaviour
- psychological stress associated with psychotic episode
- antipsychotic medications (olanzapine, amisulpride) with QT-prolonging properties
- failure to maintain continuous patient observation during restraint blanket application
- failure to apply supplemental oxygen despite visible cyanosis
- delayed recognition and response to patient deterioration
- failure to keep clinician at head of patient during restraint
- five-hour delay in ambulance response due to system capacity and initial triage bias
- lack of paramedic awareness of increased cardiac arrest risk in psychiatric patients
Coroner's recommendations
- That education and training be provided to SA Ambulance Service paramedics to explore and further analyse the increased risk of psychiatric patients suffering out-of-hospital sudden cardiac events and the impact of psychiatric medication upon the likelihood of a cardiac event
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