Finding into death of Trevor William Brown

49y · Male·Hypoxic brain injury following cardiac arrest due to myocardial infarction with right coronary artery thrombosis

Trevor William Brown, a 49-year-old Aboriginal man with chronic schizophrenia, died from hypoxic brain injury following cardiac arrest due to acute myocardial infarction with right coronary artery thrombosis while in psychiatric care. He was admitted to the Koori Inpatient Psychiatric Unit at St Vincent's Hospital on 13 January 2017 following escalating mental health crisis and aggressive behaviour. He required mechanical restraint due to combative presentation and was appropriately monitored per Mental Health Act requirements. On 14 January, he was found unresponsive at 4:10am; resuscitation was initiated but he suffered significant hypoxic brain injury during the cardiac arrest. The coroner found he died from natural causes and was satisfied restrictive measures complied with legislation and monitoring was appropriate. No clinical mismanagement was identified.