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Finding into death of Geoffrey Alan Locks

Deceased

Geoffrey Alan Locks

Demographics

50y, male

Date of death

2019-01-04

Finding date

2021-12-21

Cause of death

Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (treated)

AI-generated summary

A 50-year-old man died from tracheostomy site haemorrhage 36 days after laryngectomy for recurrent laryngeal cancer. He lived alone post-discharge with a MePACS personal alarm system and home nursing visits. When bleeding occurred at 21:49 on 3 January, he texted his wife rather than activating his alarm immediately. The alarm was activated at 00:54 on 4 January. MePACS staff attempted voice contact but Mr Locks could not respond verbally. Critical issue: MePACS did not have documented communication preferences despite knowing he was non-verbal. Staff asked open-ended questions futilely before contacting his wife and then requesting ambulance at 01:05. Paramedics arrived 1:13 but faced access delays due to a concurrent police incident. Though no delay occurred once ambulance was appropriately requested, earlier activation or streamlined non-verbal protocols might have expedited response. Hospital discharge care was appropriate; death was likely not preventable despite earlier ambulance arrival.

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

Specialties

ENT surgeryoncologyemergency medicineparamedicinegeneral practicespeech pathology

Error types

systemcommunication

Drugs involved

methadone

Clinical conditions

laryngeal squamous cell carcinomarecurrent squamous cell carcinomatracheostomy site haemorrhageacquired brain injuryschizophreniaattention deficit hyperactivity disordertype 2 diabetes mellitushepatitis c (treated)hepatitis baortic valve repair status

Procedures

laryngectomyhemithyroidectomynode dissectionfree flap reconstructiontracheostomyintubation via stomamassive transfusion protocol

Contributing factors

  • Defect in small calibre artery (thyroid branch of left carotid artery) at tracheostomy site
  • Recurrent laryngeal squamous cell carcinoma post-chemoradiotherapy and laryngectomy
  • Delayed activation of personal alarm (patient text-messaged wife instead of activating MePACS alarm immediately despite bleeding)
  • Non-verbal communication status not adequately documented in MePACS file despite being known at application
  • Lack of documented communication preferences for non-verbal clients in MePACS protocol
  • Access delays due to concurrent police incident at apartment building
  • Patient's acquired brain injury and mental health issues affecting decision-making and communication

Coroner's recommendations

  1. MePACS (Peninsula Health) should develop a policy and procedure specifically for non-verbal clients requiring that communication preferences and steps to be taken in medical emergency be recorded in the client's file and considered when responding to alerts
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