Inquest into the death of Ishmael Nawirridj
Deceased
Ishmael Nalaiyir Nangarid
Demographics
51y, male
Date of death
2018-12-05
Finding date
2020-07-17
Cause of death
Multiple organ failure due to Influenza A pneumonia, in the context of chronic kidney disease, chronic obstructive pulmonary disease, ischaemic heart disease and myasthenia gravis
AI-generated summary
Ishmael Nalaiyir Nangarid, a 51-year-old Aboriginal man with complex medical history including myasthenia gravis, chronic kidney disease, COPD, and ischaemic heart disease, died from multiple organ failure due to Influenza A pneumonia while in ICU custody. He was a prisoner with chronic health conditions requiring frequent hospitalisation (93 admissions total). The coroner identified a drug charting error involving meropenem on day 5 of ICU admission where four doses were not administered, though the ICU director opined this did not contribute to his death. The coroner commended the health service's willingness to review procedures and made no adverse findings regarding clinical care or recommendations for improvement. Key lesson: manual medication re-charting in busy ICUs creates error risk; the unit implemented full-time pharmacist coverage and electronic prescribing to mitigate this.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Influenza A infection
- Underlying chronic kidney disease (Stage 5)
- Underlying COPD
- Underlying ischaemic heart disease
- Underlying myasthenia gravis
- Drug charting error (meropenem not added to final day's chart resulting in four missed doses)
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