Coronial
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Finding into death of Victor Dale Fenech

Deceased

Victor Dale Fenech

Demographics

56y, male

Coroner

Coroner Katherine Lorenz

Date of death

2022-02-03

Finding date

2024-05-13

Cause of death

complications of metastatic colorectal carcinoma

AI-generated summary

Victor Dale Fenech, a 56-year-old experiencing homelessness, died from complications of metastatic colorectal carcinoma. He made three emergency calls over two days before his death, but ambulances did not attend the first two calls. Key issues included: the neighbour failed to provide the unit number when reporting the address of a large residential complex; the neighbour called from a disconnected mobile phone unable to receive callback calls; and ambulance resources were diverted to higher priority emergencies. The coroner found no evidence the death was preventable, as Victor refused hospital transport when contact was made, and his prognosis was poor given advanced undiagnosed cancer. However, recommendations were made to improve emergency services processes: Triple Zero Victoria should specifically prompt for unit numbers in multi-unit dwellings, and Ambulance Victoria should provide clearer guidance about when to call again and reinstate warm transfers for secondary triage callbacks.

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

Specialties

emergency medicineparamedicinepathology

Error types

communicationsystem

Drugs involved

cocainemethamphetaminepregabalinphenterminesynthetic cannabis

Clinical conditions

metastatic colorectal carcinomahepatic metastasesbronchopneumoniapulmonary embolismbullous emphysemahomelessnesssubstance use disorder

Contributing factors

  • unit number not provided when reporting address to emergency services
  • caller using disconnected mobile phone unable to receive callbacks
  • caller became verbally aggressive during calls
  • ambulance resources diverted to higher priority emergencies
  • secondary triage callback system unable to contact caller
  • undiagnosed and untreated metastatic bowel cancer
  • severe bilateral bronchopneumonia
  • pulmonary embolism
  • severe bullous emphysema
  • homelessness affecting access to medical care
  • recent injecting drug use

Coroner's recommendations

  1. That Triple Zero Victoria consider mechanisms to confirm the type of dwelling, or that additional address information is required, when verifying the address of an event to prompt direct questioning of this information.
  2. That Ambulance Victoria, in consultation with Triple Zero Victoria, consider providing information in closing scripts about when to call Triple Zero again in cases where callers are expecting a call back from another health professional, including what to do if the call back does not occur.
  3. That Ambulance Victoria, in consultation with Triple Zero Victoria, consider reinstating the inbound call warm transfer process as the primary means of facilitating secondary triage.
Full text
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