Finding into death of ALJW
Demographics
21y, male
Date of death
2014-09-15
Finding date
2017-09-21
Cause of death
Combined effects of heroin toxicity and plastic bag asphyxia
AI-generated summary
A 21-year-old man with complex congenital heart disease (Fontan procedure) died from combined heroin toxicity and plastic bag asphyxia. He had a history of depression and suicidality since childhood. In August 2014, during a cardiology review, he misinterpreted prognostic information as meaning he would be "dead by his 40s," despite clinicians providing reassuring information about good prognosis. He had recent psychological counselling for depression and suicidal ideation after an overdose attempt in early July. His previous cardiac review at age 14 had provided bleak prognostic information. The coroner found that poor communication about prognosis, lack of integrated psychological support during transition from paediatric to adult care, and failure to identify high suicide risk were significant contributing factors. Key lessons: holistic assessment of mental health in chronic disease, careful prognostic communication avoiding misinterpretation, formal psychological support during healthcare transitions, and serial mental health screening.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Misinterpretation of prognostic information about cardiac prognosis
- Lack of integrated psychological support during transition from paediatric to adult cardiac care
- Inadequate mental health assessment despite history of depression and suicidality
- Lack of formal psychological support processes for Fontan patients during transition
- Failure to refer for mental health support after cardiology review despite identified risk factors
- Recent relationship breakdown
- History of depression since childhood
- Bleak prognostic information provided at age 14
Coroner's recommendations
- Royal Children's Hospital should formally refer patients to a social worker as part of the transition decision, with the social worker remaining involved throughout the transition period and until after the first appointment at Royal Melbourne Hospital
- Royal Children's Hospital and Royal Melbourne Hospital should introduce routine, serial administration of age-appropriate screening tools measuring capacity and resilience for transition events, such as the Adolescent Resilience Questionnaire
- Royal Melbourne Hospital should require Congenital Liaison Nurses to complete mental health training such as Mental Health First Aid to improve capacity to identify and respond to patients' mental health issues
- Royal Children's Hospital and Royal Melbourne Hospital should review and change care pathways and systems to ensure focus on emotional and psychological impacts of Fontan surgery and implications for quality of life
Full text
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