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Coroner's Finding: Mansell-Moore, Codie

Deceased

Codie Anthony Mansell-Moore

Demographics

17y, male

Date of death

2018-12-10

Finding date

2024-08-09

Cause of death

epileptic seizure complicating idiopathic epilepsy

AI-generated summary

17-year-old Codie Mansell-Moore died from epileptic seizures on 10 December 2018. An ambulance was called at 6:09am while he was seizing, but paramedics staged around the corner and did not enter his home for 48 minutes due to a safety alert for Codie's father (Ronald Moore), who had previously displayed aggressive behavior. The paramedics waited for police assistance as per protocol. By the time they entered at 6:57am, Codie was in cardiac arrest and deceased. Critical clinical lessons include: medication adherence is essential in epilepsy management; delayed seizure treatment increases mortality risk; family training in emergency medication (midazolam) administration may help but cannot be assumed; communication failures between ambulance dispatch and police meant information that the father was absent was not passed to police, preventing reassessment of the two-officer response policy. If paramedics had entered earlier or midazolam been administered at home, survival was likely.

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

Specialties

emergency medicineparamedicineneurologyforensic medicine

Error types

communicationsystemdelay

Drugs involved

levetiracetammidazolamcannabis

Clinical conditions

idiopathic generalized epilepsystatus epilepticusgeneralized convulsive status epilepticus (gcse)cardiac arrestasystole

Contributing factors

  • missed antiepileptic medication dose on evening of 9 December 2018
  • cannabis use on evening prior to seizures
  • delayed access to paramedic treatment due to safety alert on address
  • failure to administer buccal midazolam at home despite family training
  • communication failures between ambulance dispatch and police regarding patient's father's absence from address
  • lack of realtime information sharing between Ambulance Tasmania and Tasmania Police via ESCAD system
  • police unavailability and two-up response policy not reassessed in light of medical urgency

Coroner's recommendations

  1. Ambulance Tasmania immediately finalise and implement the Management of Ambulance Tasmania ESCAD Alerts Procedure; once implemented, review operation of the Procedure on a regular basis and ensure required amendments are made in a timely manner.
  2. Ambulance Tasmania and Tasmania Police together review the effectiveness of joint arrangements regarding police assisting ambulance contained in the Letter of Understanding - Response to High Risk Incidents at regular intervals prior to its expiration.
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