Coronial
VIChome

Finding into death of Gordon Malcolm Wallace

Deceased

Gordon Malcolm Wallace

Demographics

71y, male

Coroner

Coroner Audrey Jamieson

Date of death

2018-11-08

Finding date

2020-06-15

Cause of death

Plastic bag asphyxia and argon gas inhalation

AI-generated summary

A 71-year-old man with metastatic bladder cancer, chronic renal failure, and recent dialysis initiation deliberately ended his life using argon gas inhalation. Over 12 years of progressive cancer treatment, multiple surgeries, and dialysis, he became increasingly despondent about quality of life. He discussed his 'end of life plan' with his wife and researched inert gas as a suicide method online. The coroner found he had capacity and clear intent. Key clinical lessons: recognize when cumulative medical burden and progressive deterioration significantly impact psychological wellbeing; document discussions about end-of-life wishes thoroughly; ensure mental health screening in patients with multiple comorbidities and functional decline. The case highlights systemic issues regarding unrestricted access to inert gases marketed for industrial use, which have no domestic applications.

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

Specialties

nephrologyoncologyurologypathologyemergency medicine

Error types

system

Drugs involved

argon gas

Clinical conditions

metastatic bladder cancerchronic renal failuredepressionsuicidal ideation

Procedures

bladder removal and stoma formationnephrectomydialysis fistula creationdialysis

Contributing factors

  • metastatic bladder cancer with 12-year disease trajectory
  • chronic renal failure requiring dialysis
  • multiple surgical interventions and medical procedures
  • progressive functional decline and loss of quality of life
  • psychological distress and pessimism about prognosis
  • unrestricted availability of argon gas for purchase online
  • inadequate mental health assessment and intervention despite clear risk factors

Coroner's recommendations

  1. The Department of Health and Human Services should consider amending the deleterious substances provisions of the Drugs Poisons and Controlled Substances Act 1981 (Vic) to specifically include argon gas, with the aim of promoting public health and safety and preventing like deaths
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