WAhospital

Inquest into the Death of Karl Albert STEINHAUSER

Deceased

Karl Albert STEINHAUSER

Demographics

30y, male

Coroner

Coroner Urquhart

Date of death

2023-03-12

Finding date

2025-12-23

Cause of death

pulmonary thromboembolism in an overweight man with comorbidities (including recent hospital-acquired pneumonia) in the setting of receiving treatment for acute exacerbation of a psychotic disorder

AI-generated summary

Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembolism on 12 March 2023 while under Mental Health Act care. After two weeks of increasingly challenging management at Kalgoorlie Health Campus for acute psychotic exacerbation, he was transferred by RFDS to Fiona Stanley Hospital ICU, intubated due to severe agitation. He died post-extubation from massive PE. Key clinical lessons: (1) The referring unit lacked adequate psychiatric infrastructure, seclusion facilities, and ECT capability for managing acutely aggressive patients; (2) Family communication was minimal despite their knowledge of de-escalation strategies; (3) Extubation was delayed two days (10-11 March) due to security unavailability despite available mental health beds; (4) Earlier extubation might have reduced VTE risk but was not definitively preventable. No SAC1 investigation occurred at FSH, severely limiting root-cause analysis. While Karl's aggressive behaviour and medication side effects created treatment challenges, the underlying systemic limitations in regional mental health infrastructure and inter-hospital transfer coordination were critical contributing factors.

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Specialties

psychiatryintensive careemergency medicineanaesthesia

Error types

systemdelaycommunication

Drugs involved

aripiprazole depotquetiapinelorazepamdroperidolzuclopenthixol acetatesodium valproatemidazolampropofolheparin

Clinical conditions

schizoaffective disorderpsychotic disorder acute exacerbationpulmonary embolismdeep vein thrombosisaspiration pneumoniaventilator-associated pneumoniapolysubstance use disorderobesityneuroleptic malignant syndrome (suspected)sinus tachycardiaright heart strain

Procedures

intubationmechanical ventilationextubationnasogastric tube insertioncardiopulmonary resuscitationthrombolysis

Contributing factors

extended intubation and immobilisation (72 hours)
hospital-acquired aspiration/ventilator-associated pneumonia
obesity (BMI 36.9)
antipsychotic medications (associated with inflammatory response and hypercoagulability)
poor mobility due to sedation
delayed extubation due to security unavailability
inadequate psychiatric infrastructure at referring facility forcing transfer
minimal family/carer engagement in behaviour de-escalation

Coroner's recommendations

In order to provide appropriate treatment to acutely unwell mental health patients in the Goldfields region without the need to transfer them to Perth for their treatment, the Court remains committed in its support for the construction of a purpose-built mental health facility at the Kalgoorlie Health Campus and recommends it be undertaken as soon as possible.
To improve the transfer of rural mental health patients to metropolitan hospitals, a working group be established that is co-led by WACHS and the Department of Health State Health Operations Centre, with input from the Mental Health Commission and the Office of the Chief Psychiatrist and other relevant stakeholders. The purpose of the working group is to ensure processes are in place to support the implementation of the Statewide Mental Health Bed Access, Capacity and Escalation Policy 2025, particularly the referral and transfer practices, including a fast-track trial prioritisation process, of rural and regional mental health patients to metropolitan hospitals.
The Department of Health, in collaboration with relevant stakeholders across the State's health system, develops a system level process that provides oversight for the quality of care of interhospital transfers of mental health patients from rural and regional areas who are under the Mental Health Act 2014 (WA). This should include regularly reporting the numbers and modality of transfer by site (whether intubated or sedated), any morbidity or mortality related to transfer (inclusive of effects of intubation/sedation) subsequently detected, and whether the underlying reason for transfer relates to considerations such as a lack of specialised mental health infrastructure at the referring site.

Full text

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