Finding into death of Hilda Joan Berg
Deceased
Hilda Joan Berg
Demographics
89y, female
Date of death
2016-12-19
Finding date
2019-11-11
Cause of death
Aspiration pneumonia complicating electroconvulsive therapy for treatment of psychotic depression
AI-generated summary
Hilda Berg, 89-year-old woman with depression, psychosis, atrial fibrillation, chronic kidney disease and type 2 diabetes, deteriorated in hospital with refusal to eat or drink due to psychotic beliefs. After initial conservative management, compulsory ECT was approved and administered. She subsequently developed aspiration pneumonia and died. The coroner found the decision to proceed with ECT was appropriate given her deteriorating mental state and life-threatening refusal of intake. However, two clinical shortcomings were identified: (1) no second psychiatrist opinion was documented despite guidelines recommending this for complex cases, and (2) no pre-procedure chest X-ray was performed. The coroner could not find these omissions would have prevented her death or changed the ECT decision, and made no adverse findings.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Refusal of oral intake due to psychotic beliefs that food was poisoned
- Deteriorating mental state with psychotic depression resistant to medication
- Multiple medical comorbidities (atrial fibrillation, chronic kidney disease, acute kidney injury, diabetes, history of myocardial infarction, stroke)
- Probable aspiration during anaesthesia for ECT
- Absence of pre-procedural chest X-ray
- Absence of documented second psychiatrist opinion despite guidelines recommendations
Coroner's recommendations
- Ensure that when ECT is being considered for older patients with significant medical comorbidities, psychiatric teams document whether a second psychiatrist opinion has been sought, in accordance with RANZCP guidelines
- Consider implementation of pre-procedural chest X-rays for elderly patients undergoing ECT, particularly those with risk factors for aspiration
- The Mental Health Tribunal should consider requiring information about medical fitness for ECT prior to granting an Electroconvulsive Treatment Order, and the composition of the Tribunal might need review to ensure medical fitness assessment capability
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —