Kenneth Stephens, a 51-year-old man with schizoaffective disorder, died from an unascertained cause while under involuntary psychiatric care. He presented with acute behavioural changes including excessive drinking, unusual fluid/milk consumption, repeated vomiting and faecal incontinence. Despite timely mental health service involvement and appropriate escalation to ambulance services, he suffered multiple seizures en route to hospital and died from presumed cardiac arrhythmia. The coroner found mental health management was of high standard with appropriate frequent reviews and timely responses. Ambulance Victoria's response was reasonable given initial non-urgent presentation; the case highlights the unpredictability of sudden cardiac events in patients with schizophrenia and the challenge of managing acute decompensation in community settings.
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