Finding into death of Craig Michael Akerblom
Deceased
Craig Michael Akerblom
Demographics
31y, male
Date of death
2015-04-29
Finding date
2017-12-14
Cause of death
Hypoxic ischaemic brain injury secondary to hanging
AI-generated summary
Craig Akerblom, a 31-year-old man with depression, anxiety, substance abuse, and selective eating disorder, died by hanging resulting in hypoxic-ischaemic brain injury. He had been under care of multiple clinicians (GP, psychiatrist, psychologist, dietician) but there was no coordinated care plan. In April 2015, he presented with suicidal ideation and paranoid thoughts; psychiatric admission was suggested but he declined. His psychiatrist had relocated and communication between the psychiatrist and GP was suboptimal for 19 months prior to death, though the MHI found this did not causally contribute. The coroner emphasised the need for formal shared care agreements and better coordination among treating clinicians when multiple providers manage a complex patient.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Depression with persistent suicidal ideation
- Anxiety disorder
- Substance abuse (cannabis)
- Selective eating disorder
- Lack of coordinated care plan among multiple treating clinicians
- Suboptimal communication between psychiatrist and general practitioner
- Patient's refusal of psychiatric admission
- Psychiatrist's practice relocation creating access difficulties
Coroner's recommendations
- A formal shared care agreement be created where multiple clinicians are involved with a patient, to delineate roles and areas of clinical focus, increase communication and assist clinicians to work collaboratively to optimise treatment in the patient's best interests
- Triggers for communication under the RANZCP Guidelines should include a patient's level of cooperation with the treatment plan or if the patient has ceased to attend treatment
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