Coronial
WAmental health

Inquest into the Death of Stephen Michael KELL

Deceased

Stephen Michael KELL

Demographics

35y, male

Coroner

State Coroner Fogliani

Date of death

2015-04-26

Finding date

2020-08-06

Cause of death

acute vomit aspiration in a man with acute large intestine obstruction (severe megacolon) and clozapine-induced intestinal hypomotility

AI-generated summary

Stephen Michael Kell, a 35-year-old man with treatment-resistant schizophrenia, died at Graylands Hospital from acute vomit aspiration in the setting of acute large bowel obstruction and clozapine-induced gastrointestinal hypomotility. Despite appropriate psychiatric care and clozapine treatment per 2015 guidelines, a serious medication side effect—gastrointestinal hypomotility causing severe megacolon—was not widely recognised at that time. The coroner found his treatment appropriate but highlighted that clozapine-induced gastrointestinal hypomotility is now known to carry higher mortality than agranulocytosis. Key clinical lessons: gastrointestinal monitoring for clozapine patients is essential; symptoms such as vomiting or bowel changes warrant urgent assessment; and clinicians should maintain high suspicion for gastrointestinal complications rather than attributing symptoms solely to suspected drug use. Updated guidelines and product information now emphasise this risk.

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

Specialties

psychiatrygastroenterologytoxicologyforensic medicineemergency medicine

Error types

systemdelay

Drugs involved

clozapinesynthetic cannabinoidmacrogollithium carbonateclonazepamlevetiracetamperindoprilthyroxinehyoscine bromideatropine

Clinical conditions

chronic treatment-resistant paranoid schizophreniaacute large intestine obstructionsevere megacolonclozapine-induced gastrointestinal hypomotilityconstipationcirrhosis of the liverepilepsyhypothyroidismhypertensionacute vomit aspirationasystole

Procedures

post-mortem examinationresuscitation attemptsintubation attemptairway suctioning

Contributing factors

  • clozapine-induced gastrointestinal hypomotility
  • acute large bowel obstruction with band-like sigmoid adhesion
  • severe megacolon
  • synthetic cannabinoid (AB-CHMINACA) use causing sedation and airway protection impairment
  • lack of clinical recognition of gastrointestinal hypomotility as a serious clozapine side effect in 2015
  • patient refusal of laxative therapy (Movicol)
  • advanced liver cirrhosis potentially affecting cannabinoid metabolism

Coroner's recommendations

  1. Department of Health should amend its guidelines for the Safe and Quality Use of Clozapine Therapy in the Western Australian Health System to include reference to clozapine-induced gastrointestinal hypomotility as a serious side effect and recommend gastrointestinal monitoring in accordance with draft Guidelines for Managing Specific High Risk Medications Relevant to the Organisation
  2. Pfizer Australia and Mylan Australia, in consultation with the Therapeutic Goods Administration, should consider highlighting the risk of clozapine-induced gastrointestinal hypomotility in the boxed warning that appears at the beginning of their Product Information for Clopine and Clozaril, and ensure it appears in MIMS Full Prescribing Information and Consumer Medicine Information
Full text
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