Inquest into the Death of Carroll

21y · Male·Acute hypoxic ischaemic encephalopathy and pneumonia in a man with recent traumatic neck injury and combined drug effect (principally Oxycodone)

Peter Martin Carroll, age 21, died on 8 June 2007 in the ICU at Royal Perth Hospital from acute hypoxic ischaemic encephalopathy and pneumonia following oxycodone overdose. He had been discharged that day (5 June) after orthopaedic surgery for a wrist fracture sustained while intoxicated. Carroll had a documented psychiatric history including recent involuntary mental health admission (discharged 27 May 2007) for attempted suicide, chronic alcohol abuse, depression, and psychosis. Critically, physicians at Royal Perth Hospital did not access discharge summaries from the Joondalup Health Campus mental health unit due to system access restrictions. A brief assessment by drug and alcohol nursing staff on discharge day was inadequate—no formal psychiatric review occurred despite clear risk factors for self-harm. Carroll was discharged with 20 × 20mg oxycodone tablets. That evening he consumed a fatal dose. The coroner found the death accidental, noting systemic failures in information sharing between hospitals and inadequate mental health risk assessment before discharge of a vulnerable young man to hostel accommodation.