Finding into death of Allison Naomi Eagle
Deceased
Allison Naomi Eagle
Demographics
44y, female
Date of death
2021-04-26
Finding date
2024-04-19
Cause of death
Unascertained, presumed sudden cardiac death
AI-generated summary
44-year-old woman with schizophrenia and bipolar affective disorder died unexpectedly in a psychiatric inpatient unit. She had obstructive sleep apnoea and was on multiple antipsychotic medications. On the night before her planned discharge, she received PRN sedative medications (lorazepam and olanzapam) for agitation. She was found unresponsive the following morning despite overnight observations. Autopsy revealed no structural cardiac abnormality, but toxicology showed therapeutic levels of antipsychotic drugs known to prolong QT interval. The cause of death remained unascertained, likely sudden cardiac death. The coroner found medications were appropriate and within accepted dosages. Barwon Health's review identified process improvements regarding PRN medication review, ECG protocols, observation procedures, and medical handover processes, though these were not causative of death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Drugs involved
Contributing factors
- obstructive sleep apnoea
- obesity (WHO Class II)
- antipsychotic medications with QT-prolonging potential
- schizophrenia with associated increased risk of sudden cardiac death
- use of benzodiazepines and antipsychotics in setting of sleep apnoea
Coroner's recommendations
- More regular review of PRN sedative medications with clarity of the difference between acute sedation and ongoing PRN medications
- Guidelines surrounding medication dose escalation including depots
- Clear policy surrounding routine ECGs for consumers on psychotropic medications and guidelines on appropriate use of investigations in inpatient units
- Articulation of nursing observations overnight and after sedation in procedures
- Articulation of the medical handover process in the Swanston Centre
- Improved documentation of non-medical strategies employed to reduce agitation
- Articulation of how nursing visual observations are to be undertaken in procedures
- Update to night-time observation procedures to require close observation and recording of breathing via chest rise and fall, audible breathing and movement, with rousing and vital signs if unarousable
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 —