Coroner's Finding: Shrimpton, Dallas Brooks
Deceased
Dallas Brooks Shrimpton
Demographics
54y, male
Date of death
2017-12-19
Finding date
2020-06-30
Cause of death
carbon monoxide asphyxia
AI-generated summary
Dallas Brooks Shrimpton, a 54-year-old man with severe alcohol dependence, chronic depression, and multiple previous suicide attempts, died by carbon monoxide asphyxiation. He presented to Royal Hobart Hospital ED on 16 December 2017 with suicidal ideation while intoxicated. Although appropriately triaged and assessed by psychiatric staff, he waited several hours without cubicle availability before being discharged voluntarily with community support. He had discharged himself from an inpatient withdrawal unit two days earlier against medical advice. Key clinical lessons include: poor information-sharing between facilities (LGH, IPWU, RHH) limited psychiatric assessment; the 3.5-hour ED wait contributed to him leaving and attempting suicide with his belt; and lack of documented discharge from protective custody orders. The coroner found the death not reasonably preventable given his capacity and voluntary treatment choices, though systemic gaps in communication and bed availability were noted.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- severe alcohol dependence with 45 standard drinks per day consumption
- chronic depression with multiple previous high-lethality suicide attempts
- prescription opioid and medication overuse
- lack of inter-facility communication between LGH, IPWU, and RHH
- extended waiting period in ED without cubicle availability
- early discharge from IPWU against medical advice
- inadequate monitoring while waiting in ED
- lack of documented discharge from protective custody order
Coroner's recommendations
- Improved inter-facility communication and information-sharing between LGH, IPWU, and RHH through shared electronic patient systems
- Implementation of Digital Medical Record (DMR) forms to notify other health services when patients discharge against medical advice from facilities like IPWU
- Review and clarification of documentation for release from protective custody orders
- Enhancement of transport options for patients from north/north-western Tasmania requiring admission to IPWU (addressed through funding of varied transport options)
- Review of Alcohol and Drug Dependency Act 1968 as out-dated and not evidence-based (currently before Parliament for repeal)
- Implementation of DMR in IPWU to allow other THS entities visibility of relevant patient information
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