Finding into death of Orce Petrusevski
Deceased
Orce Petrusevski
Demographics
35y, male
Date of death
2008-11-23
Finding date
2015-08-11
Cause of death
Unascertained, following autopsy. Likely drowning but circumstances undetermined.
AI-generated summary
A 35-year-old man with chronic alcohol dependence was admitted to the ED with acute alcohol withdrawal and auditory hallucinations. Despite presenting with objective signs of withdrawal (tremor, elevated BP, tachycardia, ECG changes), he was not prescribed thiamine, was not reviewed by senior ED clinicians, and was discharged after 24 hours without appropriate psychiatric review or family involvement. The discharging psychiatrist was unaware of his ED management. He was found dead in a flooded creek 7 days later, cause undetermined. Key failures: inadequate supervision of an inexperienced intern, lack of senior clinician review prior to discharge, failure to prescribe thiamine despite severe withdrawal presentation, poor interdisciplinary communication between ED and psychiatry, and discharge without family contact. While the coroner could not establish causation due to undetermined cause of death, significant process failures in clinical care were identified.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Failure to prescribe thiamine despite severe alcohol withdrawal and protocol requirements
- Inadequate supervision of junior intern doctor
- Lack of senior clinician review prior to discharge
- Poor communication between ED and psychiatric teams
- Inadequate psychiatric assessment prior to discharge
- Discharge without family contact despite patient's vulnerable state
- Chaotic ED environment with unclear responsibility between teams
- Undocumented handover of care
- Failure to follow up on pathology results
- Lack of formal discharge planning
Coroner's recommendations
- Implementation of improved clinical response to patients with toxicology-related medical issues
- Enhanced supervision protocols for junior doctors in ED
- Mandatory senior clinician review prior to discharge for complex cases
- Improved interdisciplinary communication between ED and psychiatry teams
- Clear protocols regarding which team is responsible for discharge decisions
- Mandatory thiamine provision for all alcohol withdrawal cases
- Formal documentation of handover procedures
- Protocols ensuring family involvement in discharge planning unless documented safety reasons
- Follow-up on all pathology results before handover
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