Coronial
SAhospital

Coroner's Finding: PETTER Elemer

Deceased

Elemer Petter

Demographics

79y, male

Date of death

2005-02-03

Finding date

2006-12-14

Cause of death

myocardial infarction

AI-generated summary

A 79-year-old man with significant comorbidities (ischaemic heart disease, diabetes, peripheral vascular disease) was admitted to hospital with anorexia and weight loss. He developed acute confusion and delirium, initially refusing vascular intervention for gangrenous toes. He was detained under mental health legislation due to acute delirium and lack insight. Chest pain developed, indicating acute myocardial infarction. On the day of death, a MET call identified extensive acute MI. Given his age, comorbidities, poor prognosis, and refusal of invasive treatment, a palliative approach was agreed with his close friend. The coroner found treatment was of extremely high standard with appropriate clinical decision-making, though noted inadequate documentation of the 'not for resuscitation' decision and Dr L.'s unfamiliarity with relevant hospital protocol.

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

Specialties

cardiologypsychiatryvascular surgerygeneral medicineemergency medicine

Error types

communication

Drugs involved

haloperidolmidazolam

Clinical conditions

myocardial infarctionacute deliriumunstable anginaischaemic heart diseasecongestive cardiac failureperipheral vascular diseasegangrenemitral regurgitationpulmonary hypertensioninsulin-dependent diabetes

Procedures

coronary angiogramfemoral angiogramECG monitoringintramuscular injection

Contributing factors

  • acute delirium secondary to medical illness
  • extensive acute myocardial infarction
  • advanced age with multiple comorbidities
  • severe peripheral vascular disease with gangrene
  • patient refusal of invasive interventions
  • poor prognosis limiting treatment options
Full text

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