Finding into death of WM
Deceased
WM
Demographics
76y, male
Date of death
2016-11-09
Finding date
2018-04-23
Cause of death
Respiratory arrest in the setting of metastatic malignancy
AI-generated summary
WM was a 76-year-old man incarcerated at the time of his death. He presented to his general practitioner on 18 October 2016 with anorexia, increased urinary frequency, and abdominal tenderness, initially treated for urinary tract infection. Persistent nausea prompted further investigation, revealing abnormal liver function tests. On 31 October 2016, abdominal ultrasound at Ballarat Base Hospital identified liver lesions highly suggestive of metastatic disease, prompting urgent transfer to St Vincent's Hospital. Imaging confirmed multiple liver metastases with a suspected primary lung lesion. Clinical decision-making was complicated by disparate recommendations from the Medical Oncology team (palliative care focus) and Respiratory team (lung biopsy), causing delayed palliative care referral. On 9 November 2016, the patient developed acute tachypnea and a Medical Emergency Team was activated. Comfort care with morphine and midazolam infusions was initiated. He died of respiratory arrest. The coroner found death was due to natural causes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Procedures
Contributing factors
- metastatic malignancy with liver metastases and suspected primary lung lesion
- communication confusion between Medical Oncology and Respiratory teams regarding recommended investigations
- delayed palliative care referral
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