Coroner's Finding: COULTER Brenton Thomas

60y · Male·Ischaemic heart disease

A 60-year-old man with schizophrenia, ischaemic heart disease, previous myocardial infarction and stenting died of acute ischaemic heart disease while an inpatient in a mental health facility under an Inpatient Treatment Order. He was admitted for psychiatric management after non-compliance with clozapine. He was found unresponsive in a bathroom and resuscitation was unsuccessful. Post-mortem revealed severe coronary artery disease, myocardial scarring, and cardiomegaly. The coroner found competent management of his complex psychiatric and cardiac conditions. No preventable factors were identified, though the case highlights the ongoing risk in patients with multiple cardiac risk factors and the challenge of balancing psychiatric medication risks against cardiac disease risk.