Coronial
QLDother

Mickelo, Garnett Allan

Deceased

Garnett Allan Mickelo

Demographics

48y, male

Coroner

Lock

Date of death

2012-11-24

Finding date

2016-07-06

Cause of death

myocardial infarction due to coronary atherosclerosis (medically treated)

AI-generated summary

Garnett Mickelo, aged 48, died from myocardial infarction due to coronary atherosclerosis while in custody at Woodford Correctional Centre on 24 November 2012, shortly after discharge from Princess Alexandra Hospital following emergency cardiac stenting. The coroner concluded the PAH provided appropriate cardiac care and the stent angiography approach was well-justified given his clinical status and high surgical risk. However, deficiencies were identified in post-discharge medication management (incorrect drugs given, new medications delayed) and inadequate response to chest heaviness symptoms on 23 November (nursing staff did not apply the chest pain protocol and documented 'no cardiac issues' despite his significant cardiac history). Autopsy revealed myocardial infarction 1-3 days old, consistent with the reported chest heaviness. The coroner found these deficiencies, whilst regrettable, did not causally contribute to the death, which was predictable given his extensive myocardial injury. Systemic improvements have since been implemented at WCC for discharge medication reconciliation, chest pain protocol training, and clinical governance integration.

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

Specialties

cardiologycardiothoracic surgeryemergency medicineforensic medicinecorrectional health

Error types

medicationcommunicationsystemdelay

Drugs involved

isosorbide mononitrateatenolollisinoprilmetforminaspirinamiodaroneatorvastatindigoxineplerenonefurosemidelantus insulinnicotine patchomeprazoleperindopriltemazepamticagrelordiazepamparacetamol

Clinical conditions

myocardial infarctioncoronary atherosclerosisischaemic heart diseaseacute coronary syndromecongestive heart failurecardiac arrhythmiaatrial fibrillationacute kidney injurytransient ischaemic attacktype 2 diabetes mellitusdyslipidaemiahepatitis bischaemic cardiomyopathyleft ventricular dysfunctionpulmonary oedemaemphysema

Procedures

coronary angiographycoronary stenting

Contributing factors

  • chronic ischaemic heart disease with previous myocardial infarctions in 1996 and 2009
  • triple vessel coronary artery disease
  • congestive heart failure
  • acute kidney injury
  • atrial fibrillation
  • extensive myocardial scarring and recent full-thickness infarction
  • heavy smoking history
  • type 2 diabetes mellitus
  • dyslipidaemia
  • hepatitis B
  • incorrect medication administration on discharge (atenolol continuation)
  • delayed administration of new medications (ticagrelor, eplerenone)
  • inadequate response to chest heaviness symptoms on 23 November 2012
  • failure to apply chest pain protocol
  • failure to arrange post-discharge cardiology follow-up (discharge summary omission)

Coroner's recommendations

  1. Implementation of improved medication reconciliation processes at WCC through receipt of faxed discharge summaries from discharging hospitals prior to prisoner return
  2. Request that discharging hospitals supply a number of days' supply of discharge medications to prisoners upon discharge
  3. Enhanced on-site pharmaceutical support at WCC Offender Health Services (implemented July 2015)
  4. Integration of PAH discharge medications and processes into WCC clinical governance (ongoing at time of finding)
  5. Incorporation of chest pain management guidelines and 'Chest Pain/Angina/Heart Attack Flowchart' into orientation training for new staff at WCC
  6. Annual 'Basic Life Support' training for all medical staff
  7. Progressive offering of 'Corrections Emergency Nurses Training Workshop' to all nursing staff at WCC
  8. Accreditation process with Australasian Council for Health Care Standards to identify and address gaps in clinical governance at WCC
  9. Implementation of death review processes that occur promptly after death and include review of events immediately surrounding the death
  10. Tracking of clinical incidents including all Code Blue calls through PRIME clinical incident management system with in-house quality and safety meetings
  11. Faster and more comprehensive post-incident review procedures (noted Dr R. implemented new process post-finding)
Full text
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