Coronial
VIChospital

Finding into death of Craig Ronald McMillan

Deceased

Craig Ronald McMillan

Demographics

37y, male

Date of death

2013-05-01

Finding date

2015-04-23

Cause of death

Unascertained (death in custody)

AI-generated summary

Craig McMillan, 37-year-old male with chronic schizophrenia, died of undetermined cause (death in custody) after being transported by police divisional van to hospital. Despite documented tachycardia from Risperidone, this condition was not communicated to attending paramedics or police. When the patient became acutely agitated and refused voluntary admission, both CAT team and ambulance paramedics declined to transport him, resulting in police assuming transport responsibility. The patient became unresponsive during the van journey but was not checked due to limited pod camera visibility and assumption of non-responsiveness based on prior non-communication. Clinical lessons include: proactive medical inquiry before police transport, awareness of psychiatric patient cardiac risks during restraint, improved patient monitoring capability in police vehicles, and ambulance service follow-up as a precautionary measure when declining transport.

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

Specialties

psychiatryemergency medicinecardiologyforensic medicine

Error types

communicationsystemdelay

Drugs involved

risperidone

Clinical conditions

schizophreniaacute psychotic episodetachycardiacardiac arrhythmiaexcited deliriumobesityhypertension

Procedures

cardiopulmonary resuscitation

Contributing factors

  • schizophrenia with acute psychotic episode
  • tachycardia and cardiac arrhythmia risk factors not communicated to transport personnel
  • restraint and handcuffing during agitation
  • police transport of psychiatric patient as last resort
  • limited visibility of patient in police van pod
  • failure to check patient responsiveness during transport
  • obesity
  • Risperidone use
  • hypertension
  • exhaustion from struggle
  • anxiety and agitation

Coroner's recommendations

  1. When Victoria Police have responsibility for transporting a mental health patient to hospital as a last resort, the decision-making officer should proactively enquire of family members and others present whether the person has any medical conditions which may compromise wellbeing before endorsing the decision to transport.
  2. Professionals (Victoria Police, Ambulance Victoria, and CAT teams) dealing with patients suffering mental health episodes who are or are about to be restrained should be provided with a special warning by practice direction of the increased risk of death, particularly from lethal arrhythmia.
  3. Where a patient requires transport and this can only be carried out safely by police, Ambulance Victoria should follow police in close proximity as a precautionary measure.
Full text
Official source Archived copy

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Source and disclaimer

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