Finding into death of Jeffrey Coote
Deceased
Jeffrey Coote
Demographics
83y, male
Date of death
2017-03-01
Finding date
2018-01-19
Cause of death
Drowning in a man with ischaemic heart disease
AI-generated summary
An 83-year-old man with significant cardiac history (triple bypass grafts, ischaemic heart disease) died from drowning while paddling a surf ski. He was not wearing a personal flotation device (PFD) despite a lifelong involvement in water activities. The coroner could not definitively determine the precipitating cause of capsizing but noted that a cardiac event (myocardial infarction) or hypoglycaemia (he had Type 1 diabetes and his wife noted he made unusual decisions with low insulin levels) may have contributed. He had also recently developed cellulitis requiring IV antibiotics but had not sought treatment. The key clinical lesson is the critical importance of PFD use during water activities, particularly for those with cardiac disease or conditions affecting consciousness. Early recognition and management of acute infections and metabolic derangements in elderly patients with multiple comorbidities is also relevant.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Failure to wear a personal flotation device (PFD)
- Ischaemic heart disease with significant coronary artery atherosclerosis
- Type 1 diabetes mellitus with possible hypoglycaemic episodes affecting judgment
- Untreated cellulitis of right lower leg
- Solo water activity in remote location
Coroner's recommendations
- Emphasis on the importance of wearing a PFD when engaged in recreational activities on waterways, whether boating or human-powered vessels
- PFD use is particularly important during solo activities or in remote locations when self-rescue may be difficult and assistance not readily available
- Consider use of Personal Locator Beacon (PLB) or Emergency Position Indicating Radio Beacon (EPIRB) for timely notification of rescue services in the event of medical emergency or distress
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