Finding into death of Michael Desmond McWhirter

79y · Male·Acute Myocardial Infarction; Underlying multiple pathologies including vascular dementia, asbestosis, pulmonary fibrosis, ischaemic heart disease, hypertension and renal impairment

79-year-old man with complex medical history (ischaemic heart disease, pulmonary fibrosis, pacemaker, renal impairment, vascular dementia) died from acute myocardial infarction while in acute psychiatric care. He was transferred to Peter James Centre from general hospital for management of agitation and cognitive decline related to vascular dementia. That evening, he was placed in a seclusion room with door open (therapeutic placement rather than formal seclusion) and given olanzapine orally. He suffered a fatal cardiac or pulmonary event shortly after. Key issues examined: status under Mental Health Act, appropriateness of placement and medication, and systems communication failures. Systemic failure to communicate change in patient status from involuntary to voluntary was identified. The death was not reportable as the patient was no longer involuntary at time of death. Staff were unaware of status change, indicating communication system deficiencies.