Coroner's Finding: Adams, Michael Gerard

62y · Male·cardiac arrest complicating psychotic episode

Michael Adams, aged 62 with chronic treatment-resistant schizophrenia, died from cardiac arrest complicating psychotic episode at a supported residential facility. During escalating psychotic behaviour, paramedics applied a restraint blanket but failed to maintain continuous patient monitoring as required by policy. For approximately four minutes after police arrival, paramedics did not detect that Adams had deteriorated into cardiac arrest, delaying CPR initiation. Critical failures included: inadequate observation while restraining (no clinician maintained head-of-stretcher position), failure to apply supplemental oxygen despite visible cyanosis, and lack of awareness that psychiatric patients and antipsychotic medications increase sudden cardiac arrest risk. There was also a five-hour initial response delay (Priority 4 tasking not escalated appropriately). Clinical lessons: maintain constant observation during physical restraint of agitated patients; recognize sudden changes in behaviour as potentially indicating serious deterioration; appreciate the increased cardiac risk in psychiatric emergencies; apply policies requiring oxygen and head-end clinician positioning.