Inquest into the Death of Christopher John DEBNAM

Contributing factors

• Undiagnosed cardiomyopathy
• Undiagnosed and untreated obstructive sleep apnoea
• High body mass index (obesity)
• Developing pneumonia
• Sedation with haloperidol and clonazepam in a patient at risk of respiratory depression
• Progressive hypoventilation and hypercapnia during sleep
• Lack of prior physical health investigation despite known risk factors
• Visual-only respiratory observations inadequate to detect hypoventilation
• Lack of continuous oximetry monitoring
• Failure to recognize or act on 2013 SCGH ED warning that deceased should not be sedated without oxygen support available
• Poor discharge planning and communication between Graylands and community mental health services
• Patient non-compliance with physical examination due to psychiatric symptoms

Coroner's recommendations

1. Compliance with proper discharge planning between all facilities dealing with patients with mental health issues
2. Emphasis on clinical medical health issues for those suffering mental health conditions while in the community so risk factors when inpatients are properly appreciated
3. Consideration and documentation of the benefits or otherwise of oximetric observations of sedated mental health patients with other risk factors for respiratory arrest, especially sleep apnoea where visual observations may not detect hypoventilation
4. More availability of appropriate acute facilities for highly aroused mental health patients at times of essential sedation