Coronial
VICmental health

Finding into death of Paul Bernard Finck

Deceased

Paul Bernard Finck

Demographics

47y, male

Coroner

Coroner Audrey Jamieson

Date of death

2007-09-19

Finding date

2015-02-26

Cause of death

pulmonary thromboembolism and deep vein thrombosis

AI-generated summary

Paul Finck, 47, an involuntary psychiatric patient with schizophrenia, died from pulmonary thromboembolism and deep vein thrombosis while admitted to the psychiatric ward. He presented with fever, tachycardia, elevated CK levels and dehydration from walking 26km barefoot. Clinical staff considered differential diagnoses including neuroleptic malignant syndrome and infection. Despite family concerns about immobilization from sedation potentially contributing to DVT formation, the coroner found his presentation was not diagnostic of DVT, clinical staff did not predict this complication, and appropriate monitoring was provided. The condition was found unforseeable and unlikely even with admission to a medical ward. No adverse findings were made against healthcare staff.

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

Specialties

psychiatryemergency medicineendocrinologygeneral medicinepathology

Drugs involved

aripiprazolediazepamtemazepamolanzapine

Clinical conditions

schizophreniaacute psychotic episodecatatoniadeep vein thrombosispulmonary thromboembolismfeverdehydrationrhabdomyolysispossible thyrotoxicityurinary retentionpossible infection

Contributing factors

  • fever
  • dehydration
  • recent significant physical exertion (walking 26km)
  • likely immobility from catatonic presentation
  • possible infection
  • thyrotoxicity

Coroner's recommendations

  1. All Mental Health patients to have baseline clinical observations and physical assessment on arrival to the Emergency Department, documented in Emergency Management form MH/162. Dr Peter Archer, Maroondah Hospital Director Emergency Medicine to provide information and education to all Emergency Medical staff.
  2. All patients to have documented physical assessment and observations on admission to inpatient units, recorded on MH222 Chart. Dr Paul Katz, Eastern Health Mental Health Service to disseminate this information to all clinicians.
  3. All clients to have documented Clinical Risk Assessment and Management form MREH 205.2 completed on admission and Clinical Risk Review form MREH 205.1 updated each shift as per Eastern Health Mental Health Service Policy. Mental Health Services Acute Operations Manager to reinforce adherence to policy.
Full text

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