Finding into death of R T
Deceased
RT
Demographics
66y, male
Date of death
2023-09-17
Finding date
2025-03-18
Cause of death
Complications of excess alcohol intake in a man with heart disease
AI-generated summary
A 66-year-old man died from complications of excess alcohol intake in the setting of underlying heart disease. He had a 40+ year history of heavy daily alcohol consumption (12+ cans of beer plus whiskey daily), chronic pain from previous bowel surgery and hernia, and undiagnosed mild heart disease. Post-mortem toxicology showed ethanol 0.16 g/100mL and evidence of alcoholic ketoacidosis (elevated beta-hydroxybutyrate). He was on melatonin, indomethacin, mirtazapine and tramadol for pain, anxiety and depression. The coroner identified no specific clinical errors but used this case to highlight systemic gaps in Victoria's alcohol harm reduction strategy, noting a 20-year gap since the last coordinated action plan despite consistent evidence on what interventions reduce alcohol-related deaths.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- chronic heavy alcohol consumption over 40+ years
- undiagnosed mild heart disease with cardiomegaly and coronary artery disease
- chronic pain from previous bowel surgery (Hartmann's procedure)
- hernia causing ongoing pain
- self-medication with alcohol for pain management
- mental health issues including anxiety and depression
- alcoholic ketoacidosis
- lack of engagement with rehabilitation or counselling services
Coroner's recommendations
- The Victorian Government, led by the Victorian Department of Health, should develop: (i) a new Alcohol Action Plan; or (ii) a program of work (including specific actions, timeframes, accountabilities, and public reporting on implementation and evaluation) to address alcohol-related harms in Victoria
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