Inquest into the Death of Mark Andrew Burnside

45y · Male·Natural causes - cardiac arrest, most likely secondary to severe tardive dyskinesia and extreme physical distress from long-term antipsychotic medication exposure

Mark Andrew Burnside, a 45-year-old man with intellectual disability and chronic mental illness, died of natural causes on 7 November 2001 at Royal Perth Hospital. He had been prescribed thioridazine (Mellaril) for approximately 39 years from early childhood to manage behavioral disturbance. In September 2000, his GP discontinued Mellaril due to its well-documented severe long-term side effects (tardive dyskinesia), and switched him to newer atypical antipsychotics. Despite multiple medication adjustments by both his GP and a consulting psychiatrist, his behavior and abnormal movements deteriorated markedly. He was admitted to hospital on 31 October 2001 with severe tremors, fever, and dystonic reactions. Despite treatment with benztropine and benzodiazepines, he died suddenly of cardiac arrest on 7 November 2001. Post-mortem examination revealed an unascertainable cause, though severe tardive dyskinesia from long-term Mellaril exposure was likely contributory. The coroner found the care adequate under the circumstances and concluded his death arose from natural causes, most likely sudden arrhythmia secondary to extreme physical distress from tardive dyskinesia.