Inquest into the death of Gregory MASTERS

52y · Male·Polypharmacy overdose of amitriptyline and doxylamine in the context of underlying co-morbidities of obesity, cardiovascular disease and obstructive sleep apnoea

A 52-year-old man with chronic facial pain, depression, obesity, cardiovascular disease and obstructive sleep apnoea died following restraint in ICU. He had ingested a polypharmacy overdose of amitriptyline and doxylamine on 26-27 February 2017, was admitted to Nepean Hospital, and successfully managed in ICU. On 2 March, while confused and hypoxic after extubation, he became acutely agitated and refused treatment. After failed de-escalation attempts, he was restrained in prone position to enable sedation with ketamine and midazolam. He deteriorated acutely, requiring intubation and ultimately died. Medical care was appropriate throughout. The coroner found restraint was clinically justified and appropriately conducted, though one security officer's knee briefly contacted his back. The death was primarily caused by polypharmacy overdose exacerbated by comorbidities, with restraint unlikely to have materially contributed. The coroner noted good post-incident training improvements by the health district.