Coronial
SAother

Coroner's Finding: Pham, Duy Ngoc

Deceased

Duy Ngoc Pham

Demographics

35y, male

Date of death

2019-04-27

Finding date

2025-05-20

Cause of death

multiple organ failure due to out-of-hospital circulatory arrest due to perforated duodenum (operated)

AI-generated summary

35-year-old male died from multiple organ failure following out-of-hospital cardiac arrest caused by perforated duodenum. He was in police custody for drug-related charges and diagnosed with opioid withdrawal. Critical delays occurred: an ambulance was not called immediately after his first collapse at 4:19am despite him being classified as 'high need'; it was called at 4:38am (19 minutes late). No officer was physically present in his cell during the 41-minute period before paramedics arrived. While hospital assessments on 18-19 April were appropriate, earlier hospital admission on 19-20 April might have prevented collapse. Key lessons: high-need detainees require immediate ambulance contact per protocol; physical presence in cell is essential while awaiting ambulance; non-medical staff cannot recognise critical deterioration; clearer protocols needed distinguishing immediate medical emergencies from ongoing withdrawal symptoms.

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

Specialties

emergency medicinegeneral practicesurgeryintensive careforensic medicineparamedicine

Error types

delaycommunicationsystem

Drugs involved

methamphetamineheroinparacetamolibuprofenhyoscine butylbromidemetoclopramideloperamideondansetronpantoprazolenoradrenaline

Clinical conditions

opioid toxicityopioid withdrawalperforated duodenal ulcerperitonitisout-of-hospital cardiac arresthypoxic brain injuryischaemic hepatitisacute kidney injuryhypotensionhypoxia

Procedures

laparotomycardiopulmonary resuscitationendotracheal intubationintravenous line insertion

Contributing factors

  • perforated duodenal ulcer occurred during custody (likely 19-21 April 2019)
  • delayed ambulance call (19 minutes after decision to call)
  • lack of physical presence in cell while awaiting ambulance
  • failure to recognise critical deterioration via CCTV monitoring alone
  • non-medical police staff unable to appreciate gravity of condition
  • opioid withdrawal masking symptoms of acute surgical abdomen
  • dehydration and electrolyte disturbance during withdrawal
  • prolonged out-of-hospital cardiac arrest (approximately 26 minutes before ROSC)

Coroner's recommendations

  1. SAPOL has already implemented (11 August 2021) a clear definition of 'physical check' requiring personal in-person inspection, not CCTV-only observations
  2. SAPOL has already implemented (April 2020) contracted nursing services (Pop-Up Health) 24/7 in metropolitan custodial facilities to assist with screening and management of detainees
  3. Recommend SAPOL update GOCM to clearly specify that an officer must be physically present in the cell with a detainee at all times while awaiting arrival of an ambulance, from the time the decision is made to call an ambulance until paramedics arrive
  4. Recommend SAPOL review GOCM to make abundantly clear that for a high-need detainee requiring medical assessment, an ambulance must be called immediately, and nothing need occur before that (including medical transfer paperwork or arranging an escort)
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

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