Coroner's Finding: COCKBURN Michael Philip

40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)

Michael Cockburn, a 40-year-old man with treatment-resistant schizophrenia and documented severe adverse reactions to antipsychotic medications, was admitted to Royal Adelaide Hospital from psychiatric detention for anaemia requiring blood transfusion. He became agitated during transfusion. An inexperienced intern prescribed haloperidol 10mg IM and clonazepam 2mg IM without reviewing available documentation explicitly warning against antipsychotics. Additionally, he received excessive clozapine (400mg instead of 175mg) due to a medication chart mix-up. Approximately one hour later he suffered cardiorespiratory arrest and subsequently died from ARDS. The coroner found sedation from multiple CNS depressants combined with his comorbidities (chronic obstructive airways disease, morbid obesity, undiagnosed coronary artery disease) likely triggered collapse. Critical lessons: junior doctors must consult senior staff and thoroughly review medication alerts before prescribing psychotropic drugs in complex psychiatric patients; medication chart verification systems must prevent substitutions; restraint situations warrant registrar involvement.