Inquest into the death of Ivan METCALFE
Deceased
Ivan Metcalfe
Demographics
82y, male
Date of death
2018-04-08
Finding date
2019-09-04
Cause of death
Complications associated with advanced chronic lung disease
AI-generated summary
Ivan Metcalfe, aged 82, died of complications from advanced chronic lung disease while in prison custody. He had multiple comorbidities including diabetes, ischaemic cardiovascular disease, and atrial fibrillation. He was admitted to Prince of Wales Hospital on 1 April 2018 with community-acquired pneumonia, discharged on 30 March with drug-induced pulmonary fibrosis diagnosis, then readmitted on 1 April for congestive cardiac failure exacerbation and chest infection. He suffered a minor myocardial infarction on 4 April and declined further medical interventions on 5 April. He died on 8 April 2018. The key issue was that his wife (listed emergency contact) was not notified that he had entered end-of-life care, preventing final visits. No formal medical errors were identified in his treatment, but a systemic communication failure existed between the hospital and Department of Corrective Services regarding notification of deteriorating health status and implementation of palliative care plans.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Diabetes Mellitus Type 2
- Ischaemic cardiovascular disease
- Atrial fibrillation
- Community-acquired pneumonia
- Drug-induced pulmonary fibrosis
- Non-ST segment elevation myocardial infarction
- Congestive cardiac failure exacerbation
- Chronic type 1 respiratory failure
- Failure to communicate deteriorating health status and end-of-life care plan to emergency contact person
Coroner's recommendations
- That the Department of Corrective Services NSW amend section 13.2.2.2 Custodial Operations Policy and Procedures (COPP) to ensure that when a prisoner in the care of an external health care provider enters palliative care or end of life care, the prisoner's Emergency Contact Person (next of kin) is notified so that final visits with the prisoner can be undertaken
- That the CSNSW enter into discussions with NSW Health to amend their Memorandum of Understanding so that NSW Health staff will be responsible for advising on the custodial patient's clinical status and CSNSW staff will contact the custodial patient's Emergency Contact Person if their medical condition becomes life threatening, subject to receiving advice from NSW Health staff
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