Coroner's Finding: O'BRIEN Barbara Ann

57y · Female·right bronchopneumonia following hypoxic brain damage secondary to cardiac arrest

A 57-year-old woman with chronic schizophrenia and non-insulin dependent diabetes was admitted to a psychiatric ward after detention under the Mental Health Act. She was found in cardiac arrest on 8 December 2001 and suffered severe hypoxic brain injury, dying from bronchopneumonia. While hypoglycaemia was present (BSL 2.1-2.4 mmol/L) and has been criticised as inadequately monitored, expert evidence indicates the cardiac arrest was more likely caused by cardiac arrhythmia from antipsychotic medication (Clozapine, Lithium, Chlorpromazine) combined with underlying coronary artery disease, rather than hypoglycaemia itself. The deceased remained conscious despite low BSL levels. Direct admission to the psychiatric ward bypassing the Emergency Department, infrequent BSL testing, and lack of IV dextrose were identified as shortcomings, though expert opinion suggested these would unlikely have prevented the arrest.