Finding into death of Lionel Raymond Perry
Deceased
Lionel Raymond Perry
Demographics
44y, male
Date of death
2006-11-03
Finding date
2011-07-22
Cause of death
Cardiomegaly
AI-generated summary
Lionel Perry, a 44-year-old Aboriginal man with schizoaffective disorder and polysubstance abuse history, died from cardiomegaly (enlarged heart due to concentric ventricular hypertrophy) while an involuntary psychiatric inpatient. He presented with hypertension and withdrawal symptoms on admission; initial management including transfer to ED and GTN was appropriate. Critical gaps existed in the day of death: nursing staff failed to document finding him slumped and unsteady, did not record vital signs, and did not formally communicate concerns to medical staff. Dr W. remained unaware of these incidents until after cardiac arrest. While the coroner found no causative relationship between documentation failures and death, recommending ongoing education on contemporaneous documentation and communication protocols. The death was sudden and unpredictable, with no prior cardiac symptoms despite the significantly enlarged heart.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Concentric ventricular hypertrophy
- Hypertension
- Failure to document observations and incidents on day of death
- Failure to formally communicate concerning findings to medical staff
- Inadequate vital sign monitoring on day of death
Coroner's recommendations
- St. Vincent's Hospital (Melbourne) Limited should continue to implement all matters actioned from the Root Cause Analysis findings
- Provision of periodic education sessions for staff involved in mental health care with emphasis on the importance of timely, accurate, contemporaneous and comprehensive documentation in accordance with the Medical Record Documentation Policy
- Provision of periodic education sessions on the roles and responsibilities of nurses who undertake the role of primary nurse or contact nurse as outlined in the Primary Nursing Manual
- Continuation of annual file audits of clinical files from the mental health service for purposes of monitoring and ensuring continued compliance with the Documentation Policy
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