Coronial
QLDhospital

Cramb, Fay - aka Valmae Beck

Deceased

Fay Cramb

Demographics

64y, female

Date of death

2008-05-27

Finding date

2010-05-07

Cause of death

Haemorrhage into atheromatous plaque, due to coronary atherosclerosis

AI-generated summary

Fay Cramb, a 64-year-old woman imprisoned for 20+ years, died on 27 May 2008 from coronary atherosclerosis with haemorrhage into atheromatous plaque. She suffered an acute cardiac event on 5 May 2008 requiring emergency pacemaker insertion. After three weeks in ICU with mechanical ventilation, she was transferred to a medical ward where an equipment malfunction (fractured in-line suction system nozzle) delayed suctioning of airway secretions. The immediate clinical lesson is that clinicians should ensure proper instruction and familiarity with specialised equipment before use, particularly high-risk items. Documentation of advance health care directives proved critical—Ms Cramb had explicitly wished not to be resuscitated or artificially sustained, but lacked a formal directive. A secondary lesson concerns consent: when emergency treatment is provided to unconscious patients, medical staff must identify and consult the statutory health attorney (designated substitute decision-maker) early. The coroner found no evidence that criminal investigation priorities influenced her care, and commended the quality of acute care provided.

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

Specialties

cardiologyintensive caregeneral medicine

Error types

system

Clinical conditions

coronary atherosclerosisemphysemacirrhosistype II diabetesobstructive sleep apnoeaacute atrio-ventricular blockacute pulmonary oedemarespiratory failureacute renal failuremultiple organ failure

Procedures

pacemaker insertionmechanical ventilationrenal dialysistracheostomyin-line suctioningyankeur suctioning

Contributing factors

  • Long-standing coronary atherosclerosis
  • Emphysema
  • Cirrhosis
  • Equipment malfunction (fractured in-line suction system) that delayed airway secretion removal
  • Lack of advance health care directive despite expressed end-of-life wishes
  • Initial difficulty identifying and contacting next-of-kin

Coroner's recommendations

  1. Recommend that Offender Health Services facilitate the creation and periodic review of advance health care directives for prisoners reasonably in need of such a mechanism
  2. Recommend Offender Health Services review its Consent to Treatment policy to ensure it aligns with the substituted decision making regime set out in the Guardian and Administration Act 2000 and Powers of Attorney Act 1998
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Source and disclaimer

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