Finding into death of Michael Travis Kidd
Deceased
Michael Travis Kidd
Demographics
35y, male
Date of death
2016-12-10
Finding date
2019-10-09
Cause of death
Clozapine toxicity
AI-generated summary
A 35-year-old Aboriginal man with schizophrenia and alcohol use disorder died from clozapine toxicity while residing at a non-clinical peer recovery facility. He presented with psychiatric distress on 10 December 2016, reporting auditory hallucinations and paranoia. Staff observed him snoring extensively but did not escalate concerns or conduct adequate welfare checks. He was found deceased the following day with a suicide note; toxicology showed elevated clozapine levels. The coroner identified that staff relied inappropriately on snoring as reassurance of wellbeing, failed to recognise overdose indicators, and lacked clear escalation protocols when residents reported psychiatric symptoms. Better safety planning with input from mental health teams, overdose awareness training, and proactive checking protocols could have prevented this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Failure to escalate concerns when resident reported psychiatric distress and auditory hallucinations
- Inappropriate reliance on snoring as indicator of wellbeing
- Inadequate welfare checks despite extended snoring and known history of isolation when distressed
- Lack of specific guidance to facility staff on responding to exacerbation of psychiatric symptoms
- Non-clinical facility staff not trained to recognise overdose indicators
- Incomplete safety planning without input from treating mental health team
- Medication non-compliance and inconsistent clozapine levels prior to death
- Staff prevented from completing checks due to previous incident
Coroner's recommendations
- Mind Australia to improve safety plans to include information guiding staff on escalated responses to residents reporting distress associated with psychiatric symptoms, particularly when residents are not following safety plans or plans are ineffective, with advice from treating mental health teams.
- Mind Australia to provide training to Community Mental Health Practitioners in residential facilities about basic indicators of overdose, appropriate responses, and interaction with client contact procedures.
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