Finding into death of David Charles Shaw
Deceased
David Charles Shaw
Demographics
57y, male
Date of death
2020-07-03
Finding date
2022-03-08
Cause of death
Ischaemic and valvular heart disease
AI-generated summary
David Charles Shaw, 57, died of ischaemic and valvular heart disease with severe coronary artery atherosclerosis. He was enrolled in MePACS, a medical alarm service requiring daily button activation between 6-11am. When he failed to trigger the device on 3 July 2020, MePACS staff attempted contact but did not directly speak to Mr Shaw. Initial contact with nominated emergency contact Mr Taylor failed (disconnected number); subsequent contact with Mr Skermer at 4:14pm suggested Shaw was safe based on Skermer's claim of seeing him that morning. However, this information was not verified. On 4 July, when Shaw again failed to trigger the device, MePACS staff again contacted Skermer but did not escalate to police until 4:01pm. Police found Shaw dead in bed that evening. Clinical lesson: Medical alarm services must establish direct verification of patient safety rather than relying on third-party reports, and escalation protocols should incorporate urgency and direct assessment rather than accepting unverified reassurances from emergency contacts.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Delayed detection of patient deterioration due to reliance on third-party reassurance rather than direct verification
- Ineffective escalation protocol in medical alarm service
- Incomplete emergency contact information (disconnected phone number)
- Severe underlying coronary artery disease with multiple old infarcts
- Marked cardiomegaly
Coroner's recommendations
- The Chief Executive Officer of Peninsula Health should review and limit the time-frame within which enquiries must be made and concluded into the condition of patients who have not triggered MePACS electronic devices as expected
- MePACS should introduce a schedule of criteria setting out the minimum bases and concomitant supporting evidence by which MePACS staff may consider themselves satisfied that patients are not in need of urgent medical attention
- MePACS protocols should incorporate a requirement for direct verification of patient safety rather than accepting third-party reassurances
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