Deceased
Pamela Edith ASHLEY
Demographics
64y, female
Coroner
Deputy State Coroner Vicker
Date of death
2016-02-03
Finding date
2019-05-22
Cause of death
fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suffering an acute psychotic episode requiring sedation
AI-generated summary
A 64-year-old woman with bipolar disorder, severe obstructive sleep apnoea, obesity and diabetes presented with acute psychotic relapse following stress and sleep deprivation. Initially admitted to ED where she was sedated with haloperidol and clonazepam. Despite recording hypoxia (oxygen saturation 93%) and requiring supplemental oxygen overnight, she was transferred to an aged-care psychiatric ward (Banksia Ward) the following afternoon. At 3.10 pm she received an intramuscular olanzapine injection to manage extreme agitation and refusal of care. She appeared to settle and fell asleep. At approximately 4.20 pm she was found unresponsive and could not be revived despite aggressive resuscitation. The coroner concluded the most likely cause was sudden fatal cardiac arrhythmia triggered by her acute psychiatric illness, obesity, severe sleep apnoea and sleep deprivation. Clinical lessons include: (1) patients with acute psychiatric illness and significant medical comorbidities require intensive monitoring in acute settings, not psychiatric wards; (2) critical information about hypoxia during sedation was lost in handover; (3) no formal clinical observations or continuous monitoring was performed post-sedation on the psychiatric ward; (4) the ED and psychiatric environment created a mismatch for her clinical needs.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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42y · Male·Ligature compression of the neck (hanging)
Brian Kealy, aged 42, died by hanging at Hakea Prison on 2 August 2024 while on remand. He had a complex psychiatric history including polysubstance use, personality disorders, and treatment-resistant psychotic symptoms.…
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