Cooper, David
Deceased
David John Cooper
Demographics
54y, male
Date of death
2016-04-06
Finding date
2018-09-11
Cause of death
Pneumonia due to Staphylococcus aureus
AI-generated summary
A 54-year-old man died in custody from Staphylococcus aureus pneumonia. Over 11 days before death, he presented multiple times with respiratory symptoms and requested antibiotics, but was never seen by a doctor. Key clinical concerns include: inadequate documentation of nursing assessments; two nurses auscultated his chest on day 3 with conflicting findings (crackles vs clear), but this was not escalated to medical review; vital signs were incompletely recorded; and the Q-ADDS deterioration chart was not used. While the coroner found nursing staff actions reasonable on the information available, opportunities for escalation and improved monitoring were missed. The infection was resistant to standard antibiotics, making it uncertain whether earlier diagnosis would have altered outcome. Significant system improvements have since been implemented including routine use of deterioration detection tools, SBAR communication protocols, and revised health request form triage processes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- inadequate documentation of nursing assessments and vital signs
- failure to escalate conflicting chest auscultation findings to medical officer
- lack of doctor review despite repeated presentations with progressive respiratory symptoms
- non-use of Queensland Adult Deterioration Detection System (Q-ADDS) chart
- incomplete communication between nursing staff and visiting medical officer
- missed opportunity for chest x-ray and earlier diagnosis
- patient refusal of medical attention on final day, not escalated to health staff
- S. aureus resistant to standard community-acquired pneumonia antibiotics
- rapid deterioration of secondary bacterial infection following viral illness
- cardiac enlargement as contributing factor to severe outcome
Coroner's recommendations
- The review underway by a working group of QH and QCS examining the existing Memorandum of Understanding and Operating Guidelines should include consideration of Mr Cooper's death and relevant coronial findings
- Where a Hospital and Health Service conducts a Root Cause Analysis in relation to a prisoner death and concerns are identified relating to Correctional Services policies and practices, the health service should liaise with QCS to jointly review and take appropriate action, ensuring mechanism for gathering QCS information including staff interviews
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —