Finding into death of Armin Andrew Schaefer

Contributing factors

• Inadequate medical assessment in ED prior to transfer to psychiatric unit
• Lack of ECG and blood tests in ED despite multiple sedative medications
• Failure to communicate prior medication-induced oversedation event and ICU admission to psychiatric unit staff
• No documentation of airway risk in psychiatric unit management plans
• Staff reluctance to approach patient due to aggressive behaviour
• Inadequate observations - vital signs not recorded, only visual checks
• Failure to escalate care when patient placed in recovery position
• Polypharmacy with CNS-depressing medications causing sedation and respiratory depression
• Multiple QT-prolonging medications increasing risk of lethal arrhythmia
• Underlying cardiac risk factors - severe coronary atherosclerosis, cardiomegaly
• Emphysema and chronic poor gas exchange
• Obesity contributing to airway compromise

Coroner's recommendations

1. Northern Health should introduce an Emergency Department procedure whereby complex psychiatric patients receiving sedative medications receive appropriate investigations, including a 12-lead ECG and any other clinically indicated measures, where safe to do so prior to discharge
2. Any Northern Health mental health patient requiring airway support, whether positional or otherwise, should receive an urgent medical review and ongoing comprehensive monitoring as clinically indicated
3. Introduction of an ED policy/guideline regarding minimum requirements for medical clearance of complex psychiatric patients, including where possible ECG on patients receiving multiple drugs with potential cardiac side effects
4. Introduction of medical alert section in all psychiatric admission documentation
5. Rationalization of medication charting
6. Introduction of standard observation and response charts used in medical wards to psychiatric units for patients identified as meeting criteria for increased observation
7. Mandatory medical review for psychiatric unit patients identified as requiring increased medical observations
8. Mandatory medical review of any psychiatric unit patient placed in recovery position to protect airway
9. Development of procedure to admit mental health patients at high risk of significant medical complications to appropriate medical setting with nursing and medical care
10. Northern Health to review application of Safer Care Victoria reporting guidelines regarding recognition and escalation of care in deteriorating patients