Coroner's Finding: DELLATORRE Natale
Deceased
Natale DellaTorre
Demographics
54y, male
Date of death
1997-02-09
Finding date
2000-05-31
Cause of death
respiratory failure and acute renal failure due to rhabdomyolysis following trauma
AI-generated summary
A 54-year-old man with chronic schizophrenia and intellectual disability died from respiratory failure and acute renal failure secondary to rhabdomyolysis following a crush injury to his left thigh sustained while attempting to escape from a psychiatric hospital. He became trapped hanging upside down on a perimeter fence on 19 January 1997. Initial assessment at Royal Adelaide Hospital ED missed early signs of rhabdomyolysis (elevated potassium on blood tests), though the coroner found this was not a serious error given rhabdomyolysis's rarity in isolated thigh injury. Staff at Glenside Hospital provided exemplary monitoring post-injury. Once rhabdomyolysis became established, his death became almost inevitable despite comprehensive ICU management including dialysis, intubation, and tracheostomy. Communication breakdown occurred between ICU staff and family regarding withdrawal of treatment.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- crush injury to left thigh with compartment syndrome
- myoglobinuria secondary to rhabdomyolysis
- dehydration from high ambient temperature (36.8°C) during entrapment
- ischaemic damage to muscle tissue
- organising pneumonia
- acute tubular necrosis
Coroner's recommendations
- Director of Intensive Care at Royal Adelaide Hospital should consider steps to avoid misunderstandings between ICU staff and families regarding treatment decisions, particularly ensuring close family members understand the issues being discussed and their rights to be involved
- Forms documenting revision of treatment should be individually signed and dated by each doctor concerned rather than one doctor signing on behalf of others
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