Deceased
Kenneth Alfred Stead
Demographics
79y, male
Date of death
2010-11-24
Finding date
2012-09-19
Cause of death
delirium due to aspiration pneumonia complicating advanced metastatic non-small cell lung cancer (stage 4)
AI-generated summary
A 79-year-old man with metastatic lung cancer suffered multiple strokes causing confusion and behavioural disturbance. He was detained under Mental Health Act. On the night shift, nursing staff found him unresponsive and pulseless but failed to call a Code Blue or commence resuscitation despite a documented full resuscitation order. The on-call doctor appropriately instructed Code Blue activation when reached, but the patient was already deceased for several minutes. The coroner found the failure to call Code Blue breached hospital protocol but made no difference to outcome, as the patient was irreversibly dead when discovered. Key lessons include ensuring clear communication between nursing staff during acute deterioration, adhering to resuscitation protocols regardless of perceived prognosis, and seeking senior guidance promptly when uncertain.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
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