Finding into death of ALJW

21y · Male·Combined effects of heroin toxicity and plastic bag asphyxia

A 21-year-old man with complex congenital heart disease (Fontan procedure) died from combined heroin toxicity and plastic bag asphyxia. He had a history of depression and suicidality since childhood. In August 2014, during a cardiology review, he misinterpreted prognostic information as meaning he would be "dead by his 40s," despite clinicians providing reassuring information about good prognosis. He had recent psychological counselling for depression and suicidal ideation after an overdose attempt in early July. His previous cardiac review at age 14 had provided bleak prognostic information. The coroner found that poor communication about prognosis, lack of integrated psychological support during transition from paediatric to adult care, and failure to identify high suicide risk were significant contributing factors. Key lessons: holistic assessment of mental health in chronic disease, careful prognostic communication avoiding misinterpretation, formal psychological support during healthcare transitions, and serial mental health screening.