No case to answer on death of Vaggs

"MISSED opportunities" culminated in the death of a mentally ill indigenous man in Townsville Hospital, a coroner has found.

Gracelyn Smallwood

"MISSED opportunities" culminated in the death of a mentally ill indigenous man after he was physically restrained in hospital, handcuffed and dosed with a drug that would have suppressed his breathing, a coroner has found.

But while he questioned the treatment of Lyji Vaggs, a father of three, Queensland Coroner Michael Barnes said there was no case for anyone to be prosecuted or disciplined.

Mr Vaggs's family last night reacted with dismay. His aunt, prominent indigenous heath activist Gracelyn Smallwood, said the family could not understand how Mr Barnes could find the system failed the young man without calling for action against those responsible. "All his mother said today, and she was so devastated, was that she wanted justice for her boy," Ms Smallwood told The Australian.

Vaggs, 27, agreed to be taken to Townsville Hospital's Acute Mental Health Unit on April 13, 2010, by outreach staff after seeking treatment for psychotic hallucinations. He had been battling a schizophrenia-like condition for years.

Vaggs lashed out in the hospital carpark, punching a medical student who had helped bring him in. A melee erupted as staff and security tried to restrain him in the foyer of the AMHU, where he was held face-down on the floor for more than 30 minutes.

He was injected with 10mg of the sedative olanzapine at 3.10pm, and another dose was given 10 minutes later, just before police arrived. They handcuffed Vaggs, after which he got a third injection, this time of midazolam.

Vaggs "suddenly stopped struggling". He had suffered respiratory failure and was taken off life support two days later. Mr Barnes found the cause of death to be hypoxic brain injury sustained while Vaggs was being restrained and sedated at Townsville Hospital.

While noting that prescribing guidelines called for doses of olanzapine to be given at least two hours apart, and that the doctor involved was an intern, Mr Barnes said the "rapid sedation of psychotic patients is an issue Queensland Health has grappled with for many years". There continued to be debate among experts about what was best, he said.

He voiced concern that on-call psychiatrist David Hartman had ordered the extra 5mg of midazolam in a telephone call with staff at the mental health unit at the height of the confusion. Dr Hartman, in testimony, was adamant he had not been told Vaggs was handcuffed, and his concern was to control an increasingly dangerous situation.

Mr Barnes said he was "firmly of the view" that no further drugs had been needed. "I am concerned that Dr Hartman would order a drug known to be associated with the depression of respiration without fully ascertaining the prevailing circumstances, although I accept communication was difficult in the chaotic circumstances," he said.

Mr Barnes found Vaggs should have been admitted to hospital a day earlier, and that the subsequent events should have been better managed. "These missed opportunities culminated in Lyji Vaggs's death," Mr Barnes found. "Nothing I or the mental healthcare staff involved can do or say will ameliorate the loss of a dearly loved son, a father, a partner, a brother. I offer the family my sincere condolences."