Two case histories are described. One of the patients dies as a consequence of his acute catatonic state. The diagnosis 'neuroleptic malignant syndrome' could not be excluded. Both cases will be elucidated briefly.
With the first patient both psychiatric and practical aspects of care, like tranfers and hand-overs, interfered with an optimal treatment. These experiences were taken into consideration with the treatment of the second patient. Because of a joint effort of all participating carers, an appropriate treatment could be realised in time.