Finding into death of Ward Harker
Deceased
Ward Harker
Demographics
93y, male
Date of death
2015-12-01
Finding date
2020-01-30
Cause of death
Multisystem failure complicating sepsis secondary to perforated viscus
AI-generated summary
Ward Harker, 93 years old, died in the Alfred Hospital on 1 December 2015 from multisystem failure complicating sepsis following a perforated bowel. He was receiving palliative care. His grandson, Angus Tye, told nursing staff that he placed a pillow over his grandfather's face shortly before his death, reportedly distressed by his grandfather's apparent suffering. The coroner found that Tye did place a pillow over Harker's face but found no evidence of airway obstruction causing death. The coroner identified potential criminal conduct driven by benevolent but misguided desire to end perceived suffering. While the family had expressed concerns about the adequacy of pain management and the duration of the dying process, they did not communicate desires to hasten death to medical staff. The case highlights the importance of palliative care staff recognising family distress and providing clear communication about comfort measures, the dying process, and available support.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Perforated bowel
- Sepsis
- Advanced age with significant comorbidities including coronary artery atherosclerosis and myocardial infarction
- Family distress regarding perceived suffering during palliative care
Coroner's recommendations
- Alfred Health's Clinical Aggression, Code Grey and Restraint Committee conduct review of Alfred Health's response to the incident — so that any improvements to the security system may be identified and, where appropriate, incorporated into Alfred Health's guidelines and relevant training programs including protocols for training staff to deal with potential crime scenes
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