Coroner's Finding: BURNS John Arthur

63y · Male·cerebral infarction

John Arthur Burns, a 63-year-old man with frontotemporal dementia and motor neurone disease, died from cerebral infarction on 17 September 2006 while in Westminster Aged Care Facility after only 12 days of residence. Despite nursing staff recognising his deteriorating condition on 15 September with concerning signs (unresponsive, greyish complexion, appearing unwell), Dr C. was not contacted that day to review him or arrange hospital assessment. Haloperidol was prescribed excessively and inconsistently for behavioural management (agitation, wandering, attempted elopement, sexual disinhibition) despite successful non-pharmacological management at the preceding facility. Expert opinion suggested haloperidol, combined with respiratory compromise from motor neurone disease and post-stroke delirium, may have contributed to death. Key lessons: inappropriate use of antipsychotics as sedatives in dementia, failure to escalate clinical deterioration promptly, and inadequate understanding of behavioural manifestations of frontotemporal dementia.