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.
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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
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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