Coronial
VIChospital

Finding into death of Carey Livingstone James

Deceased

CAREY LIVINGSTONE JAMES

Demographics

73y, male

Coroner

Coroner Audrey Jamieson

Date of death

2015-05-21

Finding date

2017-02-23

Cause of death

multisystem organ failure in the context of trauma and limb fracture

AI-generated summary

A 73-year-old Indigenous man with multiple comorbidities (diabetes, hypertension, obesity, sleep apnoea, ischaemic heart disease) sustained a right ankle fracture following collision with a motor vehicle while riding a mobility scooter on 24 April 2015. The collision resulted from poor visibility at a car park exit. He was hospitalised and subsequently developed multisystem organ failure, dying on 21 May 2015. Clinical review found tazocin antibiotic therapy was not causally related to his death. His deterioration was attributed to decompensation from significant comorbidities exacerbated by immobilisation following injury. Hospital in-depth case review identified several improvement recommendations including MET call follow-up protocols and multidisciplinary family meetings. The coroner recommended car park safety measures to prevent similar incidents.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicinegeneral surgerygeneral medicinepathology

Error types

system

Drugs involved

piperacillin/tazobactamceftriaxone

Clinical conditions

multisystem organ failuretibula-fibula fracture with medial malleolus fractureaspiration pneumoniaacute on chronic renal impairmentbowel obstructiontype 2 diabetes mellitushypertensionobstructive sleep apnoeaischaemic heart diseaseperipheral neuropathydiabetic glomerulonephropathycardiac enlargementorganising pneumonia

Contributing factors

  • significant comorbid medical illnesses including respiratory and cardiac conditions
  • immobilisation following limb fracture
  • poor visibility at car park exit leading to motor vehicle collision
  • decompensation during convalescence
  • aspiration pneumonia
  • acute on chronic renal impairment

Coroner's recommendations

  1. Greater Shepparton City Council implement safety measures at car parks including the car park on the corner of Maude and Vaughan Streets with measures such as mirrors, signage and/or 'no standing' parking spaces to prevent pedestrian-vehicle collisions
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