Coroner's Finding: USHER Peter Michael

56y · Male·hypoxic ischaemic encephalopathy following insulin and benzodiazepine overdose

A 56-year-old man with depression, known to close friends but not formally disclosed to healthcare providers, deliberately ingested temazepam tablets accumulated over time and insulin stolen from his mother on 10-11 November 2018. He was found unconscious in cardiac arrest with severe hypoglycaemia. Despite paramedic resuscitation and hospital treatment including intubation, he sustained global cerebral hypoxia and died four days later. He had been placed on an Inpatient Treatment Order prior to death. The coroner found no concerns with his care or custody. Clinical lessons include the importance of mental health screening in general practice, the risks of benzodiazepine accumulation, and recognition that depression may be concealed from healthcare providers despite being known to close contacts.