Inquest into the Death of Giovanni Mario Franco

30y · Male·Acute Cardiac Dysrhythmia of Uncertain Aetiology

Giovanni Mario Franco, a 30-year-old man with schizophrenia, died on 10 March 1998 at Graylands Hospital from acute cardiac dysrhythmia of uncertain aetiology. During his final admission in February 1998, he developed severe behavioural disturbance resistant to anti-psychotic medication, progressing to medication-induced delirium. He was treated with multiple anti-psychotic agents, including an inadvertent long-acting injection, leading to suspected neuroleptic toxicity. Care was transferred to an intensive psychiatric acute care unit with enhanced nursing supervision. After withdrawal of anti-psychotic medications and treatment with electro-convulsive therapy on 9 March, he showed initial clinical improvement. He died suddenly the following morning. The coroner found the level of care, supervision, and treatment was appropriate and adequate, and death arose from natural causes—likely cardiac dysrhythmia resulting from prolonged physical stress imposed by his severe psychotic illness.