Deceased
Gordon Charles Smith
Demographics
91y, male
Date of death
2014-07-30
Finding date
2016-08-02
Cause of death
Multi-organ failure due to inanition complicating prolonged delirium of uncertain cause with contributing ischaemic and hypertensive heart disease with congestive cardiac failure, cerebrovascular disease, chronic renal impairment, and type 2 diabetes mellitus
AI-generated summary
Gordon Charles Smith, 91, died from multi-organ failure due to severe malnutrition (inanition) complicating prolonged delirium of unknown cause at Repatriation General Hospital on 30 July 2014. He had been admitted voluntarily and subsequently placed on mental health detention orders due to acute confusion and agitated behaviour. The critical clinical lesson is the need to investigate delirium urgently, especially in elderly patients with multiple comorbidities, as the cause remained uncertain despite hospitalisation. A significant systems failure occurred: Mr Smith's death was not reported to the State Coroner despite his being subject to an active Level 2 inpatient treatment order at the time of death, making it a death in custody. The failure resulted from lack of awareness by the attending medical team and poor visibility of the treatment order within the EPAS electronic medical record system. While clinical care was deemed appropriate, the reporting failure and system design flaws prevented post-mortem examination.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
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