Coroner's Finding: Evans, Jillian and John

62y · Male·Mr Evans: self-inflicted gunshot wound to head and asphyxiation by hanging. Mrs Evans: neck compression and blunt force head injuries inflicted by her husband.

In September 2013, Mr John Evans (62) killed his wife Jillian after he experienced psychosis manifesting as delusions about chemical infestation of their home. The coroner found Mr Evans was psychotic at the time of death. From May 2013, Mr Evans presented repeatedly to general practitioners with escalating anxiety and emerging delusions about neighbour's chimney smoke. He was admitted to Launceston General Hospital on 17 July after acute deterioration, correctly diagnosed with major depression with psychotic features, and treated with Risperidone. He was transferred to St Luke's hospital where psychiatrist Dr J. downgraded the diagnosis to severe anxiety disorder and prescribed only 25mg quetiapine nocturnally—insufficient for psychosis treatment. The coroner found all treating clinicians acted reasonably given information available, though documentation deficiencies and communication gaps between hospitals were identified. Early detection of psychosis was very difficult; key learning points include importance of collateral history from family, timely psychiatric consultation, adequate dosing of antipsychotics when psychosis is diagnosed, and proper documentation of involuntary status and risk assessment rationale during hospital transfers.