Deceased
Geoffrey Alan Locks
Demographics
50y, male
Coroner
Deputy State Coroner Caitlin English
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. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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