Finding into death of Erol Elmas

31y · Male·undetermined

Erol Elmas, a 31-year-old man with schizoaffective disorder, died in custody at Thomas Embling Hospital on 30 November 2022. The cause of death remains undetermined despite thorough pathological investigation. Mr Elmas was in seclusion following acute psychotic relapse and violent behaviour. Critical clinical lessons include: (1) vital signs monitoring during seclusion was inadequate—high respiratory rates (48-49 breaths/min) at 10:05pm and 10:29pm on 29 November were not escalated using standardised observation charts; (2) risk of staff violence prevented full physical examination; (3) escalation should have occurred when respiratory rate entered the 'Red Zone' requiring medical emergency. The coroner found no suspicious circumstances and appropriate medications were used. Forensicare subsequently implemented significant improvements including standardised physical health monitoring systems, mandatory use of observation charts during seclusion, clearer escalation pathways, and better integration of physical health into psychiatric care.