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Coroner's Finding: Daw Rodney Keith

Deceased

Rodney Keith Daw

Demographics

63y, male

Date of death

2018-11-05

Finding date

2022-08-18

Cause of death

acute blood loss due to self-inflicted sharp force incisional wounds of the throat and bilateral wrists and forearms

AI-generated summary

A 63-year-old man with multiple chronic conditions including psoriatic arthritis, depression, prostate cancer, and recent dental issues died by self-inflicted sharp force wounds while on approved leave from a mental health inpatient facility. He had been assessed as low risk and granted frequent leave. Clinical lessons include: the complexity of managing patients with multiple comorbidities and depression; the importance of risk assessment during periods of leave from mental health units, particularly around significant life stressors (tooth loss); and paramedic decision-making regarding Advanced Care Directives in acute trauma. The paramedics appropriately applied clinical practice guidelines, determining resuscitation was futile given massive blood loss incompatible with life.

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

Specialties

psychiatryemergency medicineparamedicinegeneral practicerheumatologyneurosurgeryurology

Drugs involved

codeinediazepamtramadolquetiapinecitalopramantiretroviral medication

Clinical conditions

depressionadjustment disorderpsoriatic arthritiscervical spondylosislumbar spondylosisprostate cancerdyslipidaemiahypertensionanxietysuicidal ideation

Contributing factors

  • multiple chronic medical conditions including psoriatic arthritis, cervical and lumbar spine degeneration
  • depression and adjustment disorder
  • recent prostate cancer diagnosis
  • dental disease requiring tooth extraction
  • recent falls and ongoing physical limitations
  • inadequate social support and isolation
  • patient's expressed distress about losing teeth and feared loss of dignity in aging
  • polypharmacy with CNS depressants

Coroner's recommendations

  1. Ambulance Tasmania to further develop CPG A0203 regarding withholding/ceasing resuscitation in specific circumstances
  2. Consider whether Advanced Care Directives require specification of individual medical conditions to which they apply
  3. Evaluate and update Ambulance Tasmania guidelines and staff education following commencement of the Guardianship and Administration Amendment (Advanced Care Directives) Act 2021
Full text

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