Coronial
VIChospital

Finding into death of MRWilson

Deceased

Edward Charles Wilson

Demographics

43y, male

Coroner

Coroner Audrey Jamieson

Date of death

2019-06-04

Finding date

2021-02-10

Cause of death

Liver failure with cirrhosis in the setting of recent paracentesis and Hepatitis C

AI-generated summary

Mr Wilson was a 43-year-old Aboriginal man with end-stage liver cirrhosis and hepatitis C who died 18 days after emergency umbilical hernia repair and one day after paracentesis drainage of 8 litres of ascites at a rural hospital. While his death was the expected outcome of terminal liver disease and medical care was reasonable, communication gaps existed. His family and Mr Wilson had disparate understandings of his prognosis—they believed he would recover and go home, while clinicians had designated him for comfort-focused terminal care with expected survival of hours to days. Mr Wilson explicitly requested family presence when dying, but this was not communicated to staff. The coroner found care appropriate but noted that explicitly conveying imminent death prognosis to Mr Wilson would have allowed him to contact family, which would have been preferable for all involved. The death certificate initially failed to record the paracentesis and incorrectly identified him as non-Aboriginal.

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

Specialties

gastroenterologyhepatologygeneral practicesurgeryintensive care

Error types

communication

Drugs involved

morphinesedation

Clinical conditions

liver cirrhosisend-stage liver diseasehepatitis Cascitesumbilical herniahepatic encephalopathyhyponatremiaalcohol use disorder

Procedures

umbilical hernia repairparacentesis

Contributing factors

  • End-stage liver disease
  • Hepatitis C
  • Alcohol use disorder preventing transplant candidacy
  • Hepatic encephalopathy
  • Recent paracentesis drainage
  • Recent emergency hernia repair
  • Communication gap regarding prognosis between clinicians and patient/family

Coroner's recommendations

  1. Appropriately identify Mr Wilson as an Aboriginal man on his death certificate and re-register the cause of death
  2. Explicitly convey terminal prognosis and expected timeframes to patients and families when implementing comfort-focused terminal care plans, to enable patients to contact loved ones
Full text

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