Coroner's Finding: Butler Mark Andrew

49y · Male·pneumonia, hypoxic brain injury and cardiac arrest

49-year-old male with chronic cannabis dependence and depression developed post-surgical delirium following emergency anterior resection for perforated diverticulum. He became acutely agitated and paranoid, was detained under mental health order, and shackled to bed. After freeing himself and being restrained by security staff, he suffered cardiac arrest with hypoxic brain injury and died. Contributing factors included failure to recognise cannabis withdrawal contributing to delirium, use of anticholinergic olanzapine potentially worsening confusion, and shackling potentially worsening paranoia. Expert opinion noted clinical errors occurred but no clear causal link to fatal outcome. Death attributed to pneumonia, hypoxic brain injury and cardiac arrest on background of coronary atherosclerosis and ischaemic heart disease.