Streader, Leon
Deceased
Leon Streader
Demographics
68y, male
Date of death
2004-02-22
Finding date
2009-10-01
Cause of death
coronary atherosclerosis worsened by heat stroke
AI-generated summary
Leon Streader, a 68-year-old man with schizophrenia, epilepsy, obesity, and coronary artery disease, died from coronary atherosclerosis worsened by heat stroke whilst residing in a level-3 accredited hostel on an extremely hot day (40.9°C). He was taking two medications (benztropine and chlorpromazine) known to impair temperature regulation and sweating. Key preventability factors include: inadequate staffing (one carer for 31 residents on a weekend); no hydration policies for extreme heat; facility without air-conditioning or functioning cooling fans; poor medical record-keeping; and inadequate supervision of medication administration. The facility lacked environmental controls and policies for managing residents at risk during extreme weather. Multiple correctable system and environmental failures contributed to this preventable death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Extreme heat exposure (40.9°C external, stiflingly hot facility with no air-conditioning)
- Medications impairing temperature regulation (benztropine and chlorpromazine)
- Inadequate staffing (one carer for 31 residents on weekend)
- No written policy for hydration management in extreme heat conditions
- Lack of functional cooling facilities (non-functional fans, no air-conditioning)
- Limited access to water between scheduled mealtimes
- Poor medical record-keeping and oversight
- Underlying coronary artery disease
- Obesity
Coroner's recommendations
- Where a doctor has a financial interest in a level three accredited facility in which the doctor treats a resident, the doctor should not issue a cause of death certificate for that resident, or alternatively the certificate should be countersigned by another independent doctor
- A review should be undertaken by the accrediting authority for level three accommodation to consider an appropriate ratio of residents to staff, and an appropriate level of training of staff and procedures
- Level three facilities which distribute medication should be required to properly document this process and consideration should be given to some form of audit to ensure medication is being received regularly by residents
- Reference guides relied upon by prescribing doctors should be reviewed to ensure there is sufficient advice regarding the risk of heat stroke as a side effect of benztropine (cogentin) and chlorpromazine (largactil)
Full text
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