Deceased
John Alexander King
Demographics
60y, male
Date of death
2017-09-14
Finding date
2020-04-23
Cause of death
Mixed drug toxicity
AI-generated summary
A 60-year-old man with schizophrenia and depression presented to Maroondah Hospital ED with acute psychotic symptoms after stopping his antipsychotic medication (trifluoperazine) due to manufacturer discontinuation. He waited over 7 hours for mental health assessment but none was provided due to unplanned staff leave. Mental health services had no backup process operational that night. He was discharged after refusing further assessment, left without documented ED care coordinator referral, and died at home from mixed drug toxicity 24 hours later. Clinical lessons: (1) when antipsychotics are discontinued, proactive substitute medication and mental health follow-up are essential; (2) ED systems must have robust backup procedures for unplanned mental health staff absences, including secondary consultation pathways; (3) timely specialist assessment during acute psychosis is critical; (4) documented follow-up coordination is essential before discharge.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
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