Finding into death of Patrick Paul
Deceased
Patrick Paul
Demographics
68y, male
Date of death
2009-08-27
Finding date
2011-10-04
Cause of death
Ischaemic heart disease and coronary artery atherosclerosis
AI-generated summary
Patrick Paul, 68, with prior myocardial infarction and coronary stents, was imprisoned for drink-driving. He missed his cardiac medications for two days. Presenting with epigastric pain radiating to his back, left chest pain, shortness of breath, sweating and tremor, he was assessed at St Vincent's Hospital on 20 August. His symptoms were attributed to possible alcohol withdrawal. Troponin and ECG were normal; he was discharged back to Melbourne Assessment Prison with aspirin and no cardiology review. He died in his cell seven days later. The coroner found ischaemic heart disease and coronary atherosclerosis as the cause. Critical clinical issues include: medication gaps during detention, misattribution of cardiac symptoms to alcohol withdrawal in a patient with known ischaemic heart disease, and failure to arrange cardiology follow-up. This prompted Justice Health to implement reassessment protocols for prisoners with drug and alcohol histories within seven days of custody.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Cardiac medications not provided for two days during transfer to Melbourne Assessment Prison
- Medical complexity rating not recorded on E*Justice system
- Acute cardiac symptoms potentially misattributed to alcohol withdrawal rather than investigated as acute coronary syndrome
- Discharge from hospital back to prison without cardiology follow-up or consultation despite known ischaemic heart disease and concerning cardiac presentation
- Prior acute myocardial infarction with coronary stents
Coroner's recommendations
- Justice Health recommends all prisoners with reported drug and alcohol intake be reassessed by an appropriately qualified health professional within seven days of custody for signs and/or symptoms of drug or alcohol withdrawal
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