Coronial
QLDhospital

Adams, Adrian John

Deceased

Adrian John Adams

Demographics

76y, male

Date of death

2021-02-27

Finding date

2022-09-23

Cause of death

Small bowel obstruction and acute renal failure, due to or as a consequence of metastatic colorectal carcinoma

AI-generated summary

Adrian Adams, aged 76, died in Princess Alexandra Hospital from small bowel obstruction and acute renal failure secondary to metastatic colorectal cancer. He was serving an eight-year sentence for sexual offences at the time of his death. The coroner found Mr Adams received appropriate medical care during incarceration, including regular clinical engagement with medical staff and consistent pain management aligned with his Advanced Health Directive (palliative care only). A minor issue of missed/incorrect medications was identified and corrected. The primary systemic issue was difficulty sourcing suitable nursing home placement after exceptional circumstances parole was approved in December 2020, due to facility capacity, information-sharing barriers, and financial complications. No clinical errors were identified in his terminal care management.

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

Specialties

palliative careemergency medicineoncologygeneral medicineforensic medicine

Error types

medicationsystem

Drugs involved

dutasteridecoloxyl with sennaparacetamolramipriloxycodonemetforminaspirinduloxetinepregabalinoxycodonemetoclopramidemacrogol

Clinical conditions

metastatic colorectal carcinomasmall bowel obstructionacute renal failuresevere hyperkalaemiahypertensiontype 2 diabetes mellitusrenal cell carcinomadepressionfibromyalgia

Procedures

hemicolectomyradical nephrectomyCT imaging

Contributing factors

  • metastatic colorectal cancer with poor prognosis
  • hypertension
  • left bundle branch block
  • type 2 diabetes mellitus
  • hypercholesterolaemia
  • severe hyperkalaemia
  • severe renal impairment
  • difficulty sourcing suitable post-release accommodation after parole approval

Coroner's recommendations

  1. Continue work on improving the process for discharging palliative care inmates to nursing homes after exceptional circumstances parole is granted, involving Queensland Health, Queensland Corrective Services, and the Parole Board
  2. Develop clear pathways to facilitate discharge, including involvement of Ipswich Hospice as identified location for palliative end-of-life patients
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Source and disclaimer

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