Coronial
VIChospital

Finding into death of Shane Anthony Pappas

Deceased

Shane Anthony Pappas

Demographics

54y, male

Coroner

Coroner Audrey Jamieson

Date of death

2021-07-03

Finding date

2024-07-29

Cause of death

quetiapine toxicity in a man with ischaemic heart disease

AI-generated summary

Shane Pappas, a 54-year-old man with ischaemic heart disease, died from quetiapine toxicity after deliberately overdosing on multiple medications on 29 June 2021. He had experienced a recent relationship breakdown and presented to Grampians Health (GH) with multiple suicide attempts within 72 hours. The Coroner found several key deficiencies in his mental health management: the initial ICU psychiatrist's assessment was inadequate, failing to comprehensively explore his suicidal ideation and with insufficient risk mitigation planning following his discharge request. The ED registrar's reassessment seven hours later was wholly inadequate without proper psychiatric evaluation. The ART clinicians did not adequately consider voluntary psychiatric admission. While St Vincent's ultimately provided appropriate assessment and made an Inpatient Assessment Order, critical gaps in GH's early assessments, continuity of care planning, and family engagement contributed to substandard care. Police response was appropriate. Lessons include need for mandatory comprehensive reassessments after significant overdoses, better collateral information gathering, improved interdisciplinary communication, and consideration of voluntary admission when compulsory orders not met.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatryemergency medicineintensive carecardiology

Error types

diagnosticcommunicationsystemdelay

Drugs involved

quetiapineescitalopramoxycodonezolpidemtemazepamdiazepam

Clinical conditions

depressionacute stress reactionsuicidal ideationintentional medication overdoseischaemic heart diseasemyocardial infarction (remote)personality disorder (Cluster C traits)cardiac arrhythmia riskquetiapine toxicityhypoxic-ischaemic brain injuryaspiration pneumoniacardiac arrestrelationship breakdown

Procedures

intubationmechanical ventilationnasogastric tube insertionintravenous medication administrationcardiopulmonary resuscitationdefibrillation

Contributing factors

  • inadequate psychiatric assessment by GH psychiatrist on 27 June 2021
  • insufficient risk mitigation planning and care coordination
  • inadequate reassessment in ED on 28 June 2021
  • failure to involve psychiatric staff (ECATT) in ED assessment after section 351 apprehension
  • lack of comprehensive safety planning despite recent overdose
  • failure to consider voluntary psychiatric admission
  • poor engagement with family despite reliance on family support
  • absence of longitudinal assessment across multiple presentations
  • residual sedating medication effects not adequately considered in early assessment
  • collapse in police presence while awaiting ambulance transport during apprehension process

Coroner's recommendations

  1. Grampians Health update the MR980 Form and Clinical Practice Protocol – Intake Assessment to ensure efforts to obtain collateral information and the success or otherwise of such efforts, plus rationale for not attempting, are documented along with collateral information regarding psychiatric/medical/social history, current symptoms, risks and strengths
  2. Grampians Health conduct a review/audit of new practices and tools including creation by CLT of separate electronic mental health files for patients admitted to medical units and the MR980 form implementation to ensure consistent use and identify barriers to effectiveness
  3. Grampians Health consider adopting robust processes to ensure staff are aware of new processes, guidelines or programs implemented following In-depth Case Reviews
Full text
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