Coroner's Finding: FALLON Peter John William

40y · Male·Unascertained; likely cardiac arrhythmia secondary to cardiomegaly and morbid obesity, possibly precipitated by agitation and psychiatric disease, with potential contribution from electrolyte disturbance

Peter John William Fallon, aged 40, died in the psychiatric intensive care unit at Queen Elizabeth Hospital on 2 February 2013 of unascertained cause. He had bipolar affective disorder, was on antipsychotic therapy, and presented with acute psychosis. Autopsy revealed morbid obesity, cardiomegaly, and cannabinoid use. The coroner found his death was likely due to cardiac arrhythmia from multiple predisposing factors rather than psychiatric detention. However, the coroner expressed serious concern about nursing care in the hours before death—specifically that staff who found him lying uncovered on the floor at 0600 hours did not cover him or place his head on a pillow, which may have identified acute deterioration. While this poor nursing care was not directly causative, it represented a failure in basic clinical observation and human dignity that contrasted with appropriate overall psychiatric treatment.