Coronial
NSWcommunity

Inquest into the death of Jacob Carr

Deceased

Jacob Daniel Carr

Demographics

53y, male

Coroner

Decision ofDeputy State Coroner Baptie

Date of death

2019-08-17

Finding date

2023-11-30

Cause of death

Gunshot wound to the left thigh with transection of femoral artery and vein; exsanguination

AI-generated summary

Jacob Carr died from a gunshot wound to his left thigh sustained during a police operation at his home. He had assaulted his elderly mother, and police responded to a domestic violence call. During confrontation, Mr Carr brandished a loaded shotgun and attempted to fire at police at close range (approximately 5 metres). A police officer discharged his firearm in defence, striking Mr Carr in the leg. Paramedics applied a tourniquet to control bleeding, but it subsequently failed during transport, resulting in catastrophic secondary haemorrhage. Clinical lessons include: the tourniquet failure appears related to either patient manipulation or equipment issues with the MAT tourniquet model then in use; ambulance protocols should ensure constant visual monitoring of tourniquets without covering them; and the failure to urgently transition from the problematic MAT to the superior SOFTT-W device contributed to the risk environment, despite management awareness of multiple prior failures.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicineparamedicinetrauma surgeryforensic medicine

Error types

systemdelay

Drugs involved

alcoholpregabalinquetiapinemirtazapine

Clinical conditions

haemorrhagic shockexsanguinationfemoral artery and vein transectiondepressionsuicidal ideationchronic keratitispolysubstance use disorder

Procedures

tourniquet applicationblood transfusionemergency surgery

Contributing factors

  • Tourniquet failure during ambulance transport
  • Secondary haemorrhage
  • Use of MAT tourniquet with known reliability issues
  • Covering of tourniquet with space blanket preventing visual assessment
  • Single paramedic in rear of ambulance
  • Delayed transition to superior SOFTT-W tourniquet device
  • Patient manipulation or accidental activation of tourniquet release mechanism

Coroner's recommendations

  1. Amend Critical Incident Guidelines to provide instruction that where a Duty Officer faces immediate resourcing constraints preventing separation of involved officers, they should consider alternative means to meet the intent of guidelines, such as ensuring body worn cameras remain operational and recording until officers can be properly separated
  2. Improve Incident Reporting concerning equipment failures to ensure they are communicated to a specified person within each directorate who has responsibility for monitoring the continued efficacy of equipment
Full text
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