Deceased
Scott Cayirylys
Demographics
45y, male
Coroner
Decision ofDeputy State Coroner Magistrate Elizabeth Ryan
Date of death
2016-09-11
Finding date
2020-03-03
Cause of death
cardiac arrest due to profound blood loss causing hypovolaemia
AI-generated summary
Scott Cayirylys, aged 45, died from cardiac arrest due to profound blood loss after self-inflicting an arm wound. The death was preventable. Critical delays occurred in emergency response due to multiple system failures: ambulance dispatch downgraded the priority code from 1C to 2A based on incorrect interpretation of protocols regarding 'V' (violence risk) classifications. NSWA staff erroneously believed ambulances should not be assigned until police arrived, contradicting actual dispatch procedures. An ambulance was not allocated for 49 minutes despite availability. Had proper procedures been followed, paramedics would have arrived much earlier when the patient would 'more than likely have survived' with intravenous fluid resuscitation. Key lessons: ensure accurate understanding of dispatch protocols among all staff; prevent manual downgrading of response codes without clinical reassessment; consider automated system controls to prevent protocol breaches; ensure timely communication between emergency services.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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