Coronial
NTother

Inquest into the death of Ryan Smiler

Deceased

Ryan Smiler

Demographics

39y, male

Date of death

2013-07-09

Finding date

2014-07-21

Cause of death

cardiac arrest caused by alcoholic cardiomyopathy

AI-generated summary

Ryan Smiler was a 39-year-old Aboriginal man who died from cardiac arrest caused by alcoholic cardiomyopathy while in custody at Darwin Correctional Centre. He had a long history of alcohol abuse, hypertension, and heart failure that he had been warned about repeatedly. While imprisoned for a traffic offence related to drink-driving, he was admitted to Katherine District Hospital with decompensated cardiac failure on 27 June 2013, where he was examined and discharged as fit for custody on 30 June. At Darwin Correctional Centre, the initial medical assessment was conducted by a nurse rather than a doctor, though this did not contribute to his death. On 2 July, he was not seen for a doctor's review as scheduled due to a lock-down, though his condition appeared stable. He presented with seizures on 2 July and was transferred to hospital where he deteriorated and died. The coroner found no criticism of the care provided and noted that medication decisions, particularly the decision not to restart warfarin, were reasonable given his liver disease and non-compliance.

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

Specialties

cardiologyemergency medicineintensive caregeneral practicecorrectional health

Error types

delay

Drugs involved

warfarindiureticscardiac medicationsthiamineelevitdiazepambenzodiazepinesanti-seizure medications

Clinical conditions

alcoholic cardiomyopathycongestive heart failuredecompensated cardiac failurehypertensionatrial thrombusventricular thrombuscoagulopathyliver diseasealcohol-related organ damageseizurescardiac arrhythmiasystolic dysfunctionacute renal failure

Procedures

intubationmechanical ventilationechocardiographyCT scanseizure management

Contributing factors

  • long-standing alcohol abuse and non-compliance with medications
  • hypertension
  • atrial thrombus formation
  • decompensated congestive cardiac failure
  • coagulopathy from alcohol-related liver disease
  • repeated warnings about prognosis ignored by patient
  • possible alcohol withdrawal seizure
  • lack of doctor's initial examination at prison clinic

Coroner's recommendations

  1. Modify the PCIS Recall Report process so that inmates triaged as urgent or high priority at reception remain on the daily Recall Report until examined by a medical practitioner, rather than dropping off if not seen
  2. Review clinic procedures to reiterate application of CARPA guidelines including examination by a medical practitioner within 24 hours of reception where necessary
  3. Continue work towards ensuring prisoners are seen as soon as possible after reception, with greater importance given to the conduct of initial assessment by doctors at the clinic
Full text
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