Deceased
Maxwell Murphy
Demographics
89y, male
Coroner
McDougall
Date of death
2014-11-24
Finding date
2020-12-18
Cause of death
multi-organ failure with pneumonia due to ingestion of a corrosive liquid (quaternary ammonium compound)
AI-generated summary
An 89-year-old man with severe dementia died from multi-organ failure following ingestion of concentrated Bacban (quaternary ammonium compound) left in his bathroom at an aged care facility. The cleaning staff member inadvertently left the chemical bottle in the resident's room. When discovered coughing, salivating and reporting burning, nursing staff called the Poisons Information Centre but provided incomplete information—stating the patient had consumed 10-15ml and was asymptomatic, when he was actually displaying significant symptoms and the actual quantity was unknown. The PIC advised observation only. Nursing staff failed to escalate to hospital despite the patient later coughing blood. Hospital admission was delayed approximately 2.5 hours. Clinical lessons: (1) always assume worst-case ingestion volume when unwitnessed; (2) provide complete clinical information to PIC including symptoms and medications; (3) escalate immediately when corrosive ingestion is suspected with any symptoms; (4) implement systems to prevent chemicals remaining in resident spaces; (5) ensure adequate monitoring and documentation of vital signs.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
22y · Male·Airway obstruction due to laryngeal abscess and laryngeal chondronecrosis due to…
Kyle Gallagher, age 22, died from airway obstruction due to laryngeal abscess and chondronecrosis following a motorcycle accident. A CT scan on 13 July 2023 showed a critically narrowed (3mm) subglottic airway with suspe…
78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …
A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…
35y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to vertebro…
A 35-year-old woman presented to a rural hospital with a three-day history of collapses, slurred speech, vomiting, and abnormal eye movements. A non-contrast CT head scan was normal, and she was discharged with a diagnos…
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. Some material may have been redacted or restricted by court order or privacy requirements. 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 — report an inaccuracy here.