Coronial
WAmental health

Inquest into the Death of David GRIEVE

Deceased

David GRIEVE

Demographics

45y, male

Date of death

2015-09-01

Cause of death

Coronary Atherosclerosis

AI-generated summary

David Grieve, a 45-year-old man with chronic schizophrenia and multiple cardiac risk factors (hypertension, diabetes, obesity, smoking), died of coronary atherosclerosis while an involuntary psychiatric patient at Graylands Hospital. He presented to Sir Charles Gairdner Hospital 11 days before death with palpitations and dyspnea, attributed to psychiatric illness after cardiac investigations appeared normal. During his final psychiatric admission, his general medical medications (antihypertensives, aspirin, cholesterol-lowering agent, diabetes medication) were not administered due to incomplete medication reconciliation while he was acutely psychotic and uncooperative. The coroner found care reasonable overall; coronary atherosclerosis is often 'silent' and difficult to detect clinically. Key lessons: medication reconciliation should be prioritized even in acute psychiatric crises, and clinicians should maintain vigilance for medical comorbidities in psychiatric patients, particularly those with multiple cardiac risk factors.

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

Specialties

psychiatrycardiologygeneral medicineemergency medicine

Error types

systemcommunication

Drugs involved

haloperidolclonazepamchlorpromazinetemazepamclozapinesodium valproate

Clinical conditions

schizoaffective disordercoronary atherosclerosiscoronary artery diseaseleft ventricular hypertrophyhypertensiontype 2 diabetesobesitypulmonary oedemacardiopulmonary arrest

Procedures

coronary angiographyechocardiographyresuscitation

Contributing factors

  • Coronary artery disease (50-60% vessel narrowing)
  • Left ventricular hypertrophy secondary to hypertension
  • Obesity (BMI 39.3 kg/m³)
  • Uncontrolled hypertension
  • Type 2 diabetes
  • Smoking
  • Non-adherence to antipsychotic medication prior to admission
  • Recent acute psychosis requiring sedation and restraint
  • Possible sleep apnoea or obesity-related hypoventilation
  • Possible cardiac arrhythmia (unable to be confirmed post-mortem)

Coroner's recommendations

  1. Medication reconciliation should be prioritised as soon as possible after admission, with attempts to contact community pharmacies or GPs when patients are unable to provide coherent history
  2. Medical practitioners working in mental health facilities should regard management of general medical disorders as essential, including appropriate non-psychotropic medications
  3. Clinical pharmacists should prioritise admissions and completion of medication reconciliation for new patients
  4. Consideration of clinical pathways to allow earlier voluntary or involuntary admission to hospital for patients with escalating psychotic symptoms, to avoid crisis-point admissions requiring physical restraint and heavy sedation
  5. Utilization of My Health Record systems to access medication information when patients cannot provide reliable histories
Full text
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Source and disclaimer

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