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.
Error types
Drugs involved
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
- 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.
- 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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