Coronial
WAmental health

Inquest into the Death of Stanley KING

Deceased

Stanley KING

Demographics

45y, male

Coroner

Deputy State Coroner Vicker

Date of death

2015-05-22

Finding date

2018-07-16

Cause of death

Cardiorespiratory arrest due to coronary artery disease, severe psychosis requiring antipsychotic treatment triggering laryngeal dystonia, and obesity

AI-generated summary

Stanley King, a 45-year-old man with severe psychosis, coronary artery disease, and obesity, died from cardiorespiratory arrest triggered by antipsychotic-induced laryngeal dystonia. Admitted involuntarily for acute psychotic relapse, he experienced respiratory distress from laryngeal-lingual dystonia caused by antipsychotic medications (zuclopenthixol and chlorpromazine). Despite treatment with benztropine and cessation of antipsychotics, he suffered ongoing upper airway obstruction. Critical lessons include: (1) the distinction between inspiratory and expiratory breathing difficulty is diagnostically crucial for recognising laryngeal dystonia; (2) dystonic reactions can be erratic and persist after medication withdrawal; (3) voice changes and high-pitched inspiratory breathing are significant warning signs; (4) clinicians unfamiliar with laryngeal dystonia may misattribute symptoms to asthma or anaphylaxis; (5) a penicillin-allergic patient was incorrectly prescribed Augmentin. Early recognition of upper airway dystonia and proactive airway support before arrest could potentially have changed the outcome.

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

Specialties

psychiatryemergency medicineintensive carerespiratory medicine

Error types

diagnosticmedication

Drugs involved

zuclopenthixololanzapinechlorpromazineacuphasebenztropinelorazepamclonazepamsalbutamolamoxicillin/clavulanateadrenalinehydrocortisone

Clinical conditions

laryngeal dystoniaantipsychotic-induced extrapyramidal side effectsparanoid schizophreniasevere psychosiscoronary artery diseasecoronary artery atherosclerosisobesityintellectual disabilitysleep apnoeahigh cholesterolcardiorespiratory arrest

Procedures

cardiopulmonary resuscitationintubationchest X-rayelectrocardiogramblood test

Contributing factors

  • Antipsychotic-induced laryngeal-lingual dystonia
  • Severe psychosis requiring sedation and antipsychotics
  • Underlying moderately severe coronary artery disease with focal atherosclerosis
  • Obesity
  • Erratic and unpredictable presentation of laryngeal dystonia
  • Inadequate recognition of upper airway obstruction by most clinicians
  • Respiratory distress not fully appreciated as laryngeal dystonia
  • Medication non-compliance leading to acute psychotic relapse
  • Unclear diagnosis leading to treatment of multiple potential causes (asthma, anaphylaxis)

Coroner's recommendations

  1. Those caring for patients treated with antipsychotic medication should be trained to record in clinical notes whether any noted breathing difficulty relates to inspiration or expiration, as this distinction provides a diagnostic tool in recognising potential laryngeal dystonia and prompting medication and intensive breathing support prior to arrest.
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