Finding into death of Gerard Guy Vaz

Contributing factors

• Non-adherence to Eastern Health sedation guidelines regarding physical observations post-zuclopenthixol acetate injection
• Cessation of vital sign monitoring at 7:45am on 4 April 2015, despite guidelines requiring observations for up to 72 hours
• Absence of ECG on 4 April 2015 despite guidelines requiring ECG at 24 hours post-injection
• Inadequate monitoring of apnoeic episodes occurring during sedation and physical restraint
• Multi-drug sedation with three QT-prolonging anti-psychotic agents without adequate cardio-respiratory monitoring
• Failure to escalate patient to intensive care or high-dependency unit despite documented respiratory deterioration
• Pre-existing QT prolongation and obstructive sleep apnoea not adequately accounted for in sedation management
• Hypoventilation from sedative medications combined with existing sleep apnoea
• Possible cardiac arrhythmia from combination of QT-prolonging drugs in setting of hypoxia

Coroner's recommendations

1. Eastern Health acknowledged issues and has implemented internal recommendations: (a) review clinical practice related to management and transfer of mental health patients requiring acute interdisciplinary care, with interdisciplinary care incorporated into staff training and a perioperative and mental health liaison medicine unit established at Box Hill Hospital to facilitate close monitoring and improve pathways of escalation; (b) provide training to nursing staff in acute mental health settings and junior medical staff regarding recognition and response to patient deterioration; (c) educate mental health medical and nursing staff regarding neurological observations practice guidelines. Additionally, formalized process implemented whereby ECGs performed 24 hours after zuclopenthixol acetate injection are checked by duty psychiatry registrar and reviewed and signed off by attending medical registrar on daily basis.