Coronial
WAhospital

Inquest into the Death of LEE

Deceased

David James Lee

Demographics

37y, male

Date of death

2007-07-15

Finding date

2012-06-27

Cause of death

Respiratory arrest in association with medication drug effect and alcohol intoxication

AI-generated summary

David James Lee, a 37-year-old Aboriginal man with schizophrenia, died on 15 July 2007 at Port Hedland Regional Hospital from respiratory arrest associated with medication effect and alcohol intoxication. He arrived at the ED heavily agitated after threatening his neighbour with an axe whilst intoxicated. He was appropriately sedated to a calm, drowsy state and entered the ED cooperatively. However, he received 5mg of IV Midazolam causing respiratory depression. Subsequently, he was kept heavily sedated (GCS 3-4) for over 8 hours whilst awaiting evacuation by the Royal Flying Doctor Service, based on a misconceived handover suggesting he remained dangerously aggressive. The coroner found the sustained deep sedation was inappropriate; optimal sedation for such patients should maintain rousability. When the patient removed his mask at 1:50am and subsequently received further Midazolam, he suffered severe hypoxaemia and respiratory arrest. Although resuscitation efforts were undertaken, delays in securing oxygenation via endotracheal tube were fatal. The coroner found the death preventable through lighter sedation, better documentation, and employment of security staff to reduce fear-driven over-sedation.

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

Specialties

emergency medicinepsychiatryanaesthesiaintensive care

Error types

medicationcommunicationproceduralsystem

Drugs involved

chlorpromazinediazepamolanzapinemidazolamhaloperidolrisperidonerisperdal constaflumazenilthiopental

Clinical conditions

schizophreniaparanoiaalcohol intoxicationrespiratory depressionhypoxaemiarespiratory arresttachycardiatachypnoeacyanosisconcussive head injury

Procedures

guedel airway insertionbag-mask ventilationendotracheal intubation

Contributing factors

  • Over-sedation with benzodiazepines and antipsychotics
  • Alcohol intoxication (blood alcohol 0.260%)
  • Prolonged sedation (over 8 hours) whilst awaiting evacuation
  • Misconceived handover suggesting patient remained dangerously aggressive
  • Inadequate airway management and delayed oxygenation
  • Absence of security staff leading to fear-driven over-sedation
  • Poor quality medical documentation
  • Delay in Royal Flying Doctor Service transfer

Coroner's recommendations

  1. The WACHS Pilbara should take immediate steps to employ permanent and/or ad hoc security staff to help medical staff care for and treat agitated mental health patients, so as to minimise the need for prolonged and deep sedation.
  2. The WACHS Pilbara should take immediate steps to ensure that when a patient is cared for or treated without informed consent first having been obtained, then the treating doctor should contemporaneously, or as soon as practicable thereafter, record the fact that the treatment or care has been given without consent and explain the basis upon which the treatment or care was provided.
  3. The WACHS Pilbara should take immediate steps to ensure that in the case of a patient who is unable to provide informed consent and who needs to be sedated or restrained: (i) The most limited form of sedation/restraint should be applied; (ii) Any period where a person is sedated/restrained needs to limited to the shortest possible period of time.
  4. The WACHS Pilbara and the Department of Health should consider providing greater funding for the Royal Flying Doctor Service, so that transfer times for severely mentally ill patients can be minimised.
Full text
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