Inquest into the death of NL

62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval

NL, a 62-year-old man with schizoaffective disorder and hypothyroidism, died of cardiac arrhythmia secondary to QT prolongation while an involuntary mental health inpatient. He had a known history of non-compliance with thyroxine medication. Thyroid function tests on 5 April 2019 revealed severely elevated TSH (92.7) and low thyroxine (1.6), suggesting non-compliance, but these critical results were not appropriately reviewed or actioned. A registrar endorsed the results without clinical assessment, and they were not discussed at a multidisciplinary team meeting despite prior plans to do so. Nursing observations on the night of death were inadequate—chest movement was likely mimicked by breeze through an open window rather than actual respiration. Key lessons: pathology results require active clinical review not passive endorsement; abnormal results must trigger discussion at team meetings; psychiatric units managing medically complex patients need robust systems to ensure medical escalation; observation charts must document actual respiration rates, not estimated movement.