Cooper, Gerry Maxwell
Deceased
Gerry Maxwell Cooper
Demographics
57y, male
Date of death
2010-05-12
Finding date
2012-12-07
Cause of death
Hepatic encephalopathy, end stage liver failure, alcoholic cirrhosis, end stage renal failure, diabetic nephropathy, ischaemic heart disease, coronary atherosclerosis, and hypertension
AI-generated summary
Gerry Maxwell Cooper, a 57-year-old Aboriginal man imprisoned for 23 years, died in PAH Secure Unit from natural causes: hepatic encephalopathy, end-stage liver failure, alcoholic cirrhosis, and end-stage renal failure. He had complex comorbidities including ischaemic heart disease and required regular dialysis. During his final 29-day admission, he suffered three falls, the last causing a subdural haematoma. Following this injury, palliative care and dialysis withdrawal were implemented. While the coroner found the falls contributed to clinical decision-making, similar decisions were already being considered due to his deteriorating condition and poor prognosis. Care at the hospital and correctional centres was deemed adequate. The coroner identified minor deficiencies in the falls risk assessment policy regarding definitions and documentation, which have since been amended.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- chronic renal failure requiring dialysis
- hepatic encephalopathy and liver cirrhosis
- ischaemic stroke
- falls resulting in subdural haematoma
- poor prognosis and multifactorial comorbidities
Coroner's recommendations
- Review and amend falls assessment, identification and treatment procedures to include clear definitions of what constitutes a fall and risk levels
- Ensure daily falls risk assessments are recorded and thoroughly completed
- Implement standardised falls risk management processes across facilities
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