Finding into death of H M

48y · Female·Unascertained; presumed sudden cardiac arrhythmia

A 48-year-old woman with cerebral palsy, intellectual disability, and multiple comorbidities died unexpectedly in residential care. Post-mortem examination showed acute pulmonary oedema and intra-alveolar haemorrhage with no anatomical cause identified. Toxicology revealed olanzapine—a medication she was not prescribed and had previously caused hospitalisation for deranged sodium levels. The cause of death remains unascertained, likely sudden cardiac arrhythmia. Key clinical lessons: (1) Chemical restraint via antipsychotics in disability settings requires strict oversight and authorisation; (2) Medication management protocols must prevent unauthorised access to prescribed medications for other residents; (3) Staff must document any behavioural changes that could indicate medication side-effects like hyponatraemia; (4) Enhanced medication safety controls including visual identification and witnessed administration would reduce inadvertent errors.