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Coroner's Finding: Freeman, Keith Vivian

Deceased

Keith Vivian Freeman

Demographics

71y, male

Date of death

2022-06-07

Finding date

2025-05-20

Cause of death

end-stage cardiac failure on a background of ischaemic heart disease with dilated cardiomyopathy

AI-generated summary

Keith Freeman, aged 71, died in custody from end-stage cardiac failure with ischaemic heart disease and dilated cardiomyopathy. He had complex cardiac history including previous CABG, aortic valve replacement, and implanted ICD. During imprisonment, he developed progressive dyspnoea over several months. Despite multiple consultations, chest imaging showing worsening heart failure, and referral to cardiology, there was delay in specialist assessment. He was eventually admitted to Flinders Medical Centre where echocardiography revealed severely reduced ejection fraction (<20%). Following discharge, he rapidly decompensated and died 6 days later. The coroner found medical treatment appropriate, though the case illustrates challenges in managing advanced heart failure in custodial settings and the importance of timely specialist input in deteriorating cardiac patients.

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

Specialties

cardiologyemergency medicinegeneral medicinepalliative carecorrectional health

Error types

delay

Drugs involved

furosemide

Clinical conditions

end-stage cardiac failureischaemic heart diseasedilated cardiomyopathydecompensated heart failureheart failure with reduced ejection fractionhyperthyroidismthyroiditischronic obstructive airway diseaseventricular tachycardiachronic kidney disease

Procedures

transthoracic echocardiogramcoronary artery bypass graftaortic valve replacementinternal cardiac defibrillator insertion

Contributing factors

  • complex cardiac history with severely reduced ejection fraction
  • progressive dyspnoea over months
  • delay in cardiology specialist assessment
  • rapid decompensation following discharge
  • inadequate response to initial outpatient management
Full text

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