Inquest into the Death of Jason James Sutherland MALLETT
Deceased
Jason James Sutherland MALLETT
Demographics
46y, male
Date of death
2017-03-03
Finding date
2019-12-20
Cause of death
cardiac arrhythmia in a man with coronary arteriosclerosis and myocarditis
AI-generated summary
Jason Mallett, a 46-year-old man with bipolar affective disorder and schizo-affective disorder, died from cardiac arrhythmia secondary to coronary arteriosclerosis and myocarditis while an involuntary psychiatric patient. He had significant unrecognised cardiac risk factors including metabolic syndrome, obesity, diabetes, hypertension, and hyperlipidaemia. During his final admission, he became extremely agitated due to inability to smoke, required sedation and seclusion, then died overnight while sleeping. Two ECGs performed during admission appeared normal and did not detect the underlying coronary disease later found at autopsy. The coroner identified that while his psychiatric care was appropriate, better coordination between mental and physical health services, ongoing cardiovascular risk assessment, and implementation of pulse oximetry monitoring after sedation might have identified deterioration earlier.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- unrecognised coronary artery disease
- myocarditis
- metabolic syndrome
- obesity
- diabetes mellitus type 2
- hypertension
- hyperlipidaemia
- acute psychological stress from inability to smoke
- extreme agitation requiring sedation
- combination of psychotropic medications
- benzodiazepines
- cannabis use
- heavy smoking history
- lack of coordination between mental and physical health services
- inadequate physical monitoring after sedation
Coroner's recommendations
- WA Department of Health should consider utilising pulse oximetry in mental health patients who have been agitated and required significant sedation, for a suitable period of observation, to identify decreases in oxygen saturation that may indicate cardiac events
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