Decision ofDeputy State Coroner Magistrate Derek Lee
Date of death
2017-10-15
Finding date
2020-02-05
Cause of death
complications of a cervical spine injury
AI-generated summary
Francis McCann, a 49-year-old man in custody with a history of schizophrenia, anxiety, and self-harm, fell from his bed during sleep on 24 September 2017, sustaining a serious cervical spine injury (C4-C5 with canal stenosis). He lay on the floor for over 9 hours before discovery. Although anterior cervical discectomy and fusion surgery was performed successfully, he developed pneumonia post-operatively and died on 15 October 2017 from complications of the spinal injury. The coroner found the fall was accidental and unwitnessed. Both physical and CCTV monitoring staff reasonably assumed McCann had chosen to sleep on the floor, a common practice on warm nights. The coroner concluded no action or inaction by staff contributed to his death. Key clinical lesson: quadriplegic patients post-spinal cord injury are at high risk of serious complications including nosocomial infections.
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