Finding into death of Mark Anthony Theakston
Deceased
Mark Anthony Theakston
Demographics
45y, male
Date of death
2008-05-25
Finding date
2010-03-30
Cause of death
unascertained
AI-generated summary
Mark Anthony Theakston, a 45-year-old man with severe intellectual disability and autism residing in supported accommodation, died of an unascertained cause on 25 May 2008. He had collapsed on 21 May with a syncopal episode and head strike, examined by his GP who ordered investigations but did not arrange urgent CT imaging. He deteriorated and was found deceased four days later. Post-mortem revealed potential cardiac and metabolic pathology but no definitive cause. The coroner identified that the fall should have triggered incident reporting and review of his Health Support Needs Summary, potentially leading to closer overnight breathing checks rather than visual checks only. While the preventability of death cannot be determined given the unascertained cause, earlier documentation and reassessment of monitoring protocols may have been warranted after the acute incident.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- possible fibromuscular dysplasia of artery in atrioventricular node region
- moderate fatty change in liver (steatosis)
- previous organised focal subdural haemorrhage in right frontal lobe
- inadequate review of health monitoring needs following fall incident
- oversight checks did not include breathing assessment
Coroner's recommendations
- Every resident in supported accommodation requires a health plan with a Health Support Needs Summary that must be reviewed/updated following any change in health and support needs
- The fall/seizure incident on 21 May 2008 should have been subject to a Category 2 incident report and should have resulted in review of Mr Theakston's health and support needs
- One possible outcome of review given the fall and possible head injury may have been to change overnight monitoring from visual sighting only to checking for breathing
- The Department of Human Services should consider strengthening procedures around incident reporting and consequent review of the Health Support Needs Summary, and/or re-emphasizing its importance to supervisors and managers of residential supported accommodation
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