Coroner's Finding: NICHOLSON James

65y · Male·hypoxic ischaemic encephalopathy complicating hanging

James Nicholson, aged 65, died from hypoxic ischaemic encephalopathy following a suicide attempt by hanging while an inpatient at Noarlunga Hospital on 18 August 2015. He had undergone extensive facial cancer surgery in January 2015, followed by chemotherapy and radiotherapy with concurrent dexamethasone from March 2015. Initial dexamethasone-induced hypomania progressed to psychosis, depression, and paranoid delusions as the dose was reduced. On 14 August, after concerning behaviour and suicidal statements at home, he was admitted to hospital where Emergency Department physician Dr H. correctly diagnosed steroid-induced psychosis and placed him on an Inpatient Treatment Order. However, psychiatrist Dr O. incorrectly revoked the order the next morning, diagnosing steroid withdrawal instead. The medical team then planned discharge without psychiatric review. Critical failures included: misdiagnosis of the underlying steroid-induced syndrome, failure to maintain the ITO, cessation of one-to-one nursing observation, non-implementation of recommended antipsychotic medication, and absence of proper psychiatric follow-up before discharge. Expert evidence confirmed the presentation was classical steroid-induced psychosis requiring continued medical management, antipsychotics, and close psychiatric monitoring.