Coroner's Finding: HARKIN Leonard Norman
Deceased
Leonard Norman Harkin
Demographics
51y, male
Date of death
2003-06-20
Finding date
2006-11-16
Cause of death
ischaemic heart disease
AI-generated summary
A 51-year-old prisoner died from ischaemic heart disease after suffering a cardiac event while being transferred between prison units. He had complained of chest pain to correctional officers, was directed to walk to the medical centre, and collapsed shortly after arrival. Nurse Long initiated CPR appropriately and paramedics continued resuscitation efforts without success. Prior cardiac investigations including stress testing had been negative. Expert review found the care provided was reasonable and appropriate given the clinical presentation. The main clinical lesson concerns the decision to have a symptomatic patient walk (over 164m, partly uphill) to medical assessment rather than using wheelchair transport for prisoners with chest pain, which the coroner recommended be implemented.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- marked coronary artery atherosclerosis in two of three major epicardial coronary arteries
- physical exertion pushing trolley with defective wheel
- patient required to walk distance to medical centre rather than wheelchair transport
- lack of oxygen and aspirin administration in initial management
Coroner's recommendations
- The Department for Correctional Services should take necessary steps to ensure that a wheelchair is available for use at each Correctional Institution to transport prisoners to the infirmary in appropriate circumstances
- Suitable guidance should be provided to Correctional Service officers concerning when wheelchairs are to be used
- A schedule for regular maintenance of laundry trolleys should be developed
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