Finding into death of Gerard Guy Vaz

61y · Male·Undetermined

Gerard Guy Vaz, a 61-year-old man with bipolar disorder, obstructive sleep apnoea, and renal impairment, was admitted to Maroondah Hospital on 2 April 2015 with acute manic relapse with psychosis. He was administered zuclopenthixol acetate on 3 April 2015 and subsequently died on 5 April 2015 from an undetermined cause. Clinical lessons include: Eastern Health sedation guidelines were not followed; vital sign monitoring ceased at 7:45am on 4 April despite guidelines requiring observations for 72 hours; no ECG was performed on 4 April despite orders and guidelines requiring ECGs at 24 hours; apnoeic episodes observed while sedated and physically restrained were not adequately escalated to intensive care monitoring; and multi-drug sedation with QT-prolonging agents without adequate cardio-respiratory monitoring in a patient with pre-existing QT prolongation and sleep apnoea represented substandard care. Adherence to existing guidelines and appropriate escalation of deteriorating patients are critical.