Deceased
Gary Ronald Burgess
Demographics
59y, male
Date of death
2021-11-19
Finding date
2023-04-27
Cause of death
Massive aspiration in the setting of intubation following complications of severe ileus (cause unknown); Schizophrenia as contributing factor
AI-generated summary
A 59-year-old man with treatment-resistant schizophrenia on long-term clozapine therapy died from massive aspiration following a severe ileus of unknown aetiology. He had documented constipation managed with laxatives, then developed progressive abdominal distension, reduced oral intake, and fever. A MET call was initiated for tachycardia and tachypnoea; he was transferred to ICU and intubated but aspirated large volumes of gastric contents, leading to hypoxia and cardiac arrest. The coroner found medical management reasonable and death unlikely preventable, but identified that non-psychiatric staff may have had lower awareness of clozapine-induced gastrointestinal complications. Recommendations focus on state-wide implementation of improved monitoring protocols, standardised bowel management templates, and education for non-psychiatric clinicians about clozapine-related gastrointestinal risks.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
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