Inquest into the Death of Pamela Edith ASHLEY

64y · Female·fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suffering an acute psychotic episode requiring sedation

A 64-year-old woman with bipolar disorder, severe obstructive sleep apnoea, obesity and diabetes presented with acute psychotic relapse following stress and sleep deprivation. Initially admitted to ED where she was sedated with haloperidol and clonazepam. Despite recording hypoxia (oxygen saturation 93%) and requiring supplemental oxygen overnight, she was transferred to an aged-care psychiatric ward (Banksia Ward) the following afternoon. At 3.10 pm she received an intramuscular olanzapine injection to manage extreme agitation and refusal of care. She appeared to settle and fell asleep. At approximately 4.20 pm she was found unresponsive and could not be revived despite aggressive resuscitation. The coroner concluded the most likely cause was sudden fatal cardiac arrhythmia triggered by her acute psychiatric illness, obesity, severe sleep apnoea and sleep deprivation. Clinical lessons include: (1) patients with acute psychiatric illness and significant medical comorbidities require intensive monitoring in acute settings, not psychiatric wards; (2) critical information about hypoxia during sedation was lost in handover; (3) no formal clinical observations or continuous monitoring was performed post-sedation on the psychiatric ward; (4) the ED and psychiatric environment created a mismatch for her clinical needs.