Coroner's Finding: Bond, Johnathon Lee
Deceased
Johnathon Lee Bond
Demographics
51y, male
Date of death
2019-07-26
Finding date
2020
Cause of death
mixed prescription drug toxicity (amisulpride, diazepam and mirtazapine)
AI-generated summary
A 51-year-old man with schizophrenia, depression and early dementia died from mixed prescription drug toxicity (amisulpride, diazepam, mirtazapine) after a deliberate overdose. He had recently presented to hospital with suicidal ideation and auditory hallucinations. After police custody and court appearance, he was released with approximately 5kg of prescribed medication and went to his brother's home. Critical delays occurred in ambulance dispatch—the first call came at 5:30pm but the ambulance didn't arrive until 6:34pm (64 minutes later). Despite initial Priority 2 classification being potentially appropriate, it should have been upgraded to Priority 1 after subsequent calls indicating deteriorating consciousness and overdose intent. The coroner identified clear response delays but made no formal recommendations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- delay in ambulance dispatch and response
- failure to upgrade priority classification from Priority 2 to Priority 1 despite deteriorating clinical information
- lack of appropriate mental health follow-up and support after hospital discharge
- medication non-compliance
- acute marital disharmony and family violence
- accumulation of large quantity of medication in patient's possession
- high level of suicidal ideation with command hallucinations
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