Coronial
WAhospital

Inquest into the Death of Monique Jacinta GOMEZ

Deceased

Monique Jacinta GOMEZ

Demographics

48y, female

Coroner

Coroner Urquhart

Date of death

2023-05-29

Finding date

2025-07-11

Cause of death

intracerebral haemorrhage on a background of anticoagulation therapy for a recent embolic stroke in a woman with a mechanical aortic valve

AI-generated summary

Monique Jacinta Gomez, a 48-year-old woman with schizoaffective disorder and a mechanical aortic valve, died from intracerebral haemorrhage while receiving anticoagulation therapy for a recent embolic stroke. She was admitted to FSH for neuro-rehabilitation following an ischaemic stroke caused by non-compliance with warfarin. During admission, she developed acute psychotic symptoms and was placed on an involuntary treatment order. She required restraint for administration of enoxaparin due to aggressive refusal of anticoagulation. The coroner found the supervision, treatment and care provided at FSH was appropriate. The death resulted from the known risk of bleeding associated with necessary anticoagulation therapy—a tragic but foreseeable complication of treating her complex medical and psychiatric conditions. Key lessons include the challenges of managing medication non-compliance in patients with psychotic disorders and the need for multidisciplinary coordination.

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

Specialties

neurologypsychiatryrehabilitation medicineintensive carecardiothoracic surgery

Drugs involved

warfarinenoxaparinclozapinepaliperidoneolanzapine

Clinical conditions

schizoaffective disorderschizophreniaembolic strokeischaemic strokeintracerebral haemorrhageinfective endocarditissepticaemiamechanical aortic valve replacement

Procedures

thrombectomythrombolysisopen heart surgery for aortic valve replacementintubation

Contributing factors

  • non-compliance with warfarin medication prior to initial stroke
  • mechanical aortic valve requiring anticoagulation
  • acute psychotic relapse with aggressive refusal of medications
  • schizoaffective disorder treatment-resistant and poorly compliant
  • complexity of managing anticoagulation in patient refusing medication
Full text

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