Inquest into the death of Stanley McIntyre

63y · Male·pulmonary emphysema

Stanley McIntyre, a 63-year-old man with severe treatment-resistant schizophrenia, died from pulmonary emphasema on 23 June 2021 while subject to a Psychiatric Treatment Order. He had advanced COAD diagnosed only one month before death. Clinicians made reasonable efforts to engage him with GP care and mental health treatment despite significant barriers including his poor insight, missed appointments, resistance to physical examination, and unreliable symptom reporting. His oxygen saturation and respiratory rates remained normal until shortly before death. Earlier diagnosis of lung disease would likely not have altered outcomes given his long-standing heavy smoking, limited capacity to change lifestyle due to mental illness, and the irreversible nature of emphysema. The coroner found no failures in mental health care proximate to death. Efforts to arrange supported accommodation were underway. The case highlights systemic challenges in coordinating housing, mental health, and disability support for complex patients with severe mental illness in the community.