Inquest into the death of Robert Phair
Deceased
Robert Phair
Demographics
37y, male
Date of death
2017-12-06
Finding date
2024-09-17
Cause of death
Cardiomegaly giving rise to lethal cardiac arrhythmia in the setting of drug toxicity
AI-generated summary
37-year-old Robert Phair died in Parklea Correctional Centre from cardiomegaly causing lethal cardiac arrhythmia in the setting of drug toxicity. He was placed in detoxification requiring four-hourly clinical observations after assessment for withdrawal from heroin, methamphetamine and benzodiazepines. Critical failures occurred: nursing staff did not read clinical notes containing the treatment plan, performed no observations after initial assessment, failed to communicate the plan to incoming shifts, and did not follow up when he refused medication. A nurse responded inadequately to his request to see a nurse. These breaches of Justice Health policy constituted professional misconduct. The initial assessment by the treating doctor was appropriate and thorough. Six nurses faced AHPRA referral with disciplinary findings of unsatisfactory professional conduct. The death was not preventable medically, but preventable failures in care delivery were identified.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- chronic methamphetamine use and associated cardiomegaly
- heroin use
- benzodiazepine use
- failure to perform four-hourly clinical observations as prescribed
- failure to read clinical notes containing treatment plan
- failure to provide adequate handovers between shifts
- failure to follow up on medication refusal
- inadequate response to patient request to see nurse
- inaccurate clinical documentation
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