Coroner's Finding: Cardwell, Phillip David
Deceased
Phillip David Cardwell
Demographics
53y, male
Date of death
2017-05-21
Finding date
2022-07-08
Cause of death
lung abscess with empyema
AI-generated summary
A 53-year-old man with schizophrenia died from lung abscess with empyema while an involuntary inpatient at a mental health facility. He had been readmitted with a respiratory infection and was treated with intravenous antibiotics that were switched to oral antibiotics when clinical improvement was noted. Despite residual pneumonia and shortness of breath on mild activity, he was transferred back to the mental health unit and died suddenly the following day. The coroner found the medical care acceptable, noting that further investigation was not indicated based on his clinical improvement at the time of transfer. No systemic failures in clinical management were identified, though procedural issues regarding notification of his death in custody were subsequently addressed.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- pneumonia with inadequate treatment response
- possible post-antibiotic treatment deterioration
- mental health comorbidity affecting clinical assessment
- heavy smoking and poor nutritional status
- obesity
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