Inquest into the Death of Radwan KANAWATI

41y · Male·atropine toxicity

A 41-year-old man with schizoaffective disorder, intellectual disability and sexual offending history died from atropine toxicity after ingesting 6-8ml of atropine liquid prescribed for hyper-salivation. He had been discharged from psychiatric hospital on a community treatment order with 17-hour daily carer support. The deceased self-administered medications including atropine from a soft plastic bottle. Critical deficiencies included: lack of awareness among clinical staff that atropine was potentially lethal at high doses; failure to communicate medication supervision responsibilities to carers in writing; provision of atropine in an easily-squeezable container; and absence of safety warnings about overdose risk. The death was accidental, likely resulting from impulsive consumption without understanding toxicity risk. The coroner found multiple system failures in the discharge planning and community care coordination, despite acknowledging the substantial effort invested in the deceased's care.