Coroner's Finding: MANSVELDERS Henri Martinus Bernardus

79y · Male·Atherosclerotic right internal carotid artery occlusion with resultant ischaemia and infarction of greater than 50% of the right middle cerebral artery territory

A 79-year-old man with significant cardiovascular disease history (prior MI, triple bypass, hypertension, hypercholesterolaemia) was admitted to psychiatric care under an Inpatient Treatment Order following suicidal ideation. While detained, he suffered a massive right middle cerebral artery territory ischaemic stroke caused by atherosclerotic internal carotid artery occlusion. He was appropriately transferred to a tertiary centre, intubated, and provided neuroprotective care in ICU. Given extensive brain necrosis and poor prognosis, palliative care was initiated and he died two days later. The coroner found detention lawful, care appropriate, and no preventable factors. The clinical lesson emphasizes that acute neurological deterioration in psychiatric inpatients requires immediate emergency assessment and imaging, which was appropriately provided here.