Coroner's Finding: McLEOD Peter Malcholm

28y · Male·Acute Dopamine Imbalance Syndrome

A 28-year-old man with first-episode psychosis presented with command auditory hallucinations after a motor vehicle accident. An EEG ordered to exclude organic causes showed very abnormal findings suggestive of partial seizure focus. Despite this critical result, the psychiatric team did not urgently consult neurology before discharging him to a home-based treatment program. He received sodium valproate prophylactically without neurology input. When he deteriorated five days later, he was admitted to the ED where he spent five hours undergoing vague "physical clearance" rather than targeted neurological assessment despite known abnormal EEG and recent antipsychotic initiation. His Glasgow coma score collapsed from 13 to 5 during this period. He was transferred to ICU, intubated, and died. The cause was determined to be acute dopamine imbalance syndrome (possibly neuroleptic malignant syndrome or lethal catatonia). Key failures: no urgent neurology consultation after abnormal EEG; discharge to community without neurological assessment; unfocused ED evaluation with failure to recognise evolving neuroleptic malignant syndrome; delayed recognition of clinical deterioration.