Coronial
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Findings into the death of John Ainsworth

Deceased

John Raymond Ainsworth

Demographics

68y, male

Date of death

2021-01-12

Finding date

2024-10-18

Cause of death

Cerebrovascular disease

AI-generated summary

John Raymond Ainsworth, a 68-year-old prisoner, died of cerebrovascular disease following a severe stroke on 25 November 2020. He had poorly controlled Type II diabetes, hypertension, and high cholesterol. Prior to his acute stroke, he experienced cognitive decline and episodes suggestive of transient ischaemic attacks that were not investigated. An independent forensic medical review found his hospital care was appropriate and timely. However, his management in prison could have been better, particularly regarding diabetic control, dietary management, and blood pressure control. The coroner found no evidence of preventable factors, though earlier investigation of neurological symptoms might have prompted vascular referral, though unlikely to have changed outcome.

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

Specialties

neurologyemergency medicinepalliative carerehabilitation medicinevascular surgeryendocrinologygastroenterology

Error types

delay

Drugs involved

metformininsulinatorvastatinaspirinamlodipineperindoprilhydrochlorothiazideamitriptylineamoxicillin/clavulanategentamicinmorphinemidazolam

Clinical conditions

acute ischaemic strokecerebrovascular diseasemiddle cerebral artery occlusionanterior cerebral artery stroketype II diabetes mellitushypertensiondysphagiaaspiration pneumoniahospital-acquired pneumoniaerosive oesophagitistransient ischaemic attack (possible)carotid artery occlusion

Procedures

intubationnasogastric tube insertionpercutaneous endoscopic gastrostomy (peg) tube insertiongastroscopyCT brain imagingCT perfusion imaging

Contributing factors

  • Type II diabetes mellitus with difficult glycaemic control
  • Hypertension with difficult blood pressure control
  • High cholesterol
  • Uncontrolled smoking
  • Prior episodes of possible transient ischaemic attacks not investigated
  • Hospital-acquired aspiration pneumonia
  • Dysphagia following stroke
  • Poor weight management and dietary control in prison

Coroner's recommendations

  1. No specific recommendations made by the coroner, as the coroner accepted that there were no comments or recommendations to be made that would assist in preventing similar deaths in the future, or that otherwise relate to public health or safety or the administration of justice.
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