Coronial
NTother

Inquest into the death of Ronnie Beasley

Deceased

Ronnie Beasley

Demographics

40y, male

Date of death

2015-06-20

Finding date

2017-01-13

Cause of death

ischaemic heart disease due to left ventricular hypertrophy and coronary artery atherosclerosis

AI-generated summary

A 40-year-old Aboriginal man with longstanding rheumatic heart disease, left ventricular hypertrophy, and coronary artery atherosclerosis died from acute myocardial infarction complicated by ventricular fibrillation while in custody. He reported chest pain at 11:04 PM and received oxygen, aspirin, and GTN by paramedics who arrived at 11:40 PM. He arrested during transport and could not be resuscitated. The coroner found care appropriate but identified procedural improvements: officers should have used portable radios to summon help without delay, brought oxygen/wheelchair to the patient rather than assisting him to walk to the post. These delays were unlikely to have altered outcome given his advanced coronary disease. Death was from natural causes.

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

Contributing factors

  • longstanding rheumatic fever
  • complete heart block history
  • coronary artery atherosclerosis with up to 60% focal narrowing
  • left ventricular hypertrophy
  • hypertension
  • hypercholesterolaemia
  • excessive alcohol intake
  • chaotic lifestyle and poor nutrition

Coroner's recommendations

  1. Correctional Services Officers should utilise communication by portable radio rather than leaving a patient unattended to fetch assistance
  2. Officers should bring oxygen and wheelchair to patient rather than assisting patient to walk to the Officer's Post
  3. Standard Operating Procedure 9.28.7 (Nightshift Post Orders) should be updated to reinforce the responsibility of Officers to carry a portable radio at all times
  4. Emergency equipment checklist including wheelchairs should be maintained and known to all officers
Full text

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