Inquest into the Death of Ejub MEHINOVIC
Deceased
Ejub MEHINOVIC
Demographics
50y, male
Date of death
2015-11-23
Finding date
2017-06-29
Cause of death
coronary artery atherosclerosis causing sudden fatal cardiac arrhythmia
AI-generated summary
Ejub Mehinovic, a 50-year-old man with treatment-resistant paranoid schizophrenia managed on clozapine, died from coronary artery atherosclerosis causing sudden fatal cardiac arrhythmia. He was under a Community Treatment Order at the time of death. After being discharged from Sir Charles Gairdner Hospital on a CTO in October 2015, his appointment with his psychiatrist on 17 November 2015 was rescheduled to 23 November 2015 due to the treating doctor's illness. He did not attend this appointment; the treating team attributed this to his known rigidity and non-cooperation with appointment changes. Delayed follow-up allowed an additional day before welfare checks identified him deceased on 25 November 2015. The coroner found his mental health care was of high standard and physical health monitoring was appropriate. The cardiac death was not predictable despite regular monitoring.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- treatment-resistant schizophrenia requiring clozapine therapy
- appointment rescheduling policy
- delayed recognition of missed appointment
- patient non-compliance with appointment changes
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