Inquest into the Death of Jason James Sutherland MALLETT

46y · Male·cardiac arrhythmia in a man with coronary arteriosclerosis and myocarditis

Jason Mallett, a 46-year-old man with bipolar affective disorder and schizo-affective disorder, died from cardiac arrhythmia secondary to coronary arteriosclerosis and myocarditis while an involuntary psychiatric patient. He had significant unrecognised cardiac risk factors including metabolic syndrome, obesity, diabetes, hypertension, and hyperlipidaemia. During his final admission, he became extremely agitated due to inability to smoke, required sedation and seclusion, then died overnight while sleeping. Two ECGs performed during admission appeared normal and did not detect the underlying coronary disease later found at autopsy. The coroner identified that while his psychiatric care was appropriate, better coordination between mental and physical health services, ongoing cardiovascular risk assessment, and implementation of pulse oximetry monitoring after sedation might have identified deterioration earlier.