Deceased
Graham Joseph Butson
Demographics
81y, male
Date of death
2015-03-22
Finding date
2018-03-29
Cause of death
aspiration of gastric contents complicating disseminated moderately differentiated adenocarcinoma of the right lung with metastases to brain
AI-generated summary
Graham Joseph Butson, aged 81, died from aspiration of gastric contents complicating undiagnosed metastatic lung cancer with brain metastases. He presented with confusion, agitation and atrial fibrillation; a lung mass was suspected but CT imaging could not be completed due to his acute delirium. He was detained under mental health legislation for safety reasons. The coroner found his death was not preventable despite extensive undiagnosed malignancy. A significant procedural concern was identified: the mandatory psychiatric review of his detention order within 24 hours was not conducted, apparently due to weekend rostering. The coroner criticised this as non-compliance with mental health legislation, noting that 'not practicable' should not be conflated with 'not convenient'. However, the review failure had no clinical impact as confirmation would have been inevitable and discharge unlikely.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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