Finding into death of Chris Pravin Prasad

51y · Male·undetermined natural causes

Chris Prasad, a 51-year-old involuntary psychiatric inpatient with schizoaffective disorder, diabetes type 2, hypertension, and obesity (BMI 30.8), was granted day leave on 17 January 2013 during extreme heat (38°C) at Casey Hospital. He was found deceased on a roadside approximately 2.3km from the hospital shortly after 7pm. Post-mortem examination showed no definitive cause of death, though neuroleptic malignant syndrome was considered but not confirmed. Key clinical issues: (1) Diabetes management was suboptimal—prescribed sliding-scale insulin doses were not administered despite blood glucose levels of 16.2 and 14.2 mmol/L; (2) Holistic risk assessment for day leave failed to adequately consider the combination of extreme heat, elevated blood glucose, high-dose antipsychotics (quetiapine, zuclopenthixol), obesity, and hypertension—all recognised heat-related mortality risk factors; (3) Hospital's own heat health alert system and risk assessment procedures did not explicitly incorporate environmental conditions or physical comorbidities. The coroner found no formal policy restricting leave in extreme weather and inadequate staff training on heat-related risks in mental health populations, particularly regarding medications that impair thermoregulation and thirst perception. Family communication regarding leave arrangements was also inadequate.