Coronial
VIChospital

Finding into death of Simon Smith

Deceased

Simon Smith

Demographics

22y, male

Coroner

Coroner Rosemary Carlin

Date of death

2016-06-09

Finding date

2019-05-10

Cause of death

acute blood loss from incised injuries to left forearm

AI-generated summary

Simon Smith, a 22-year-old with end-stage renal failure requiring dialysis and complex comorbidities, died by suicide during hospitalization. Despite multiple psychiatric assessments finding he had capacity to make treatment decisions and did not meet criteria for involuntary treatment, staff managed his expressed wish to cease dialysis through planned VCAT involvement. Key clinical lessons: (1) Ensure consistent multidisciplinary communication when managing complex end-of-life decisions, particularly with young patients facing poor prognosis; (2) Recognize vulnerability from medical complexity, youth, and unstable psychosocial factors even when cognitive capacity is preserved; (3) Consider supported decision-making assistance for patients with capacity but incomplete understanding of complex options; (4) Standardize processes for 'specialling' observations in non-mental health settings; (5) Clarify escalation pathways when clinicians disagree about mental health impact on decision-making capacity.

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

Specialties

psychiatrynephrologycardiologypain medicineintensive careemergency medicineanaesthesia

Error types

communicationsystem

Drugs involved

temazepamoxycodonemorphinebuprenorphinefentanylhydromorphoneparoxetinequetiapinecannabis

Clinical conditions

end-stage renal failurefocal segmental glomerulosclerosiscardiomyopathyrefractory hypertensionposterior reversible encephalopathy syndromeheparin-induced thrombocytopeniaviral myocarditisborderline personality disorder traitsdepressionanxietyadjustment disordernon-ST elevation myocardial infarction

Procedures

dialysis via permacatharteriovenous fistula creationcardiopulmonary resuscitation

Contributing factors

  • end-stage renal failure requiring dialysis
  • complex medical comorbidities including cardiomyopathy, posterior reversible encephalopathy syndrome, hypertensive retinopathy
  • poor prognosis and limited transplant suitability
  • depression and anxiety symptoms
  • chronic pain unrelieved by medication
  • young age with limited prior health system engagement
  • unstable social supports
  • conflicting information provided by different medical teams about prognosis and transplant eligibility
  • vulnerability from incomplete understanding of treatment options despite having decision-making capacity

Coroner's recommendations

  1. The Office of the Public Advocate review opportunities to expand support systems for people without disability but with complex/time-critical medical needs and decision-making capacity, who may be vulnerable due to incomplete information and lack of understanding of treatment options and risks; support should be independent of health services and assist in supported decision-making where patients have capacity but would benefit from assistance to ensure judgement is based on comprehensive information
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