Coronial
VIChospital

Finding into death of David James Dorling

Deceased

David James Dorling

Demographics

59y, male

Coroner

Coroner Paul Lawrie

Date of death

2024-02-04

Finding date

2026-02-10

Cause of death

multiorgan failure complicating paracetamol toxicity

AI-generated summary

David James Dorling, a 59-year-old man with multiple sclerosis, ischaemic heart disease, and diabetes, ingested 90-100 paracetamol tablets on 1 February 2024 with suicidal intent. He attended court the next day and was remanded in custody without disclosing the ingestion. He developed symptoms (vomiting, chest pain, dizziness) during transport and police custody but attributed them to benign causes. Only at midnight on 3 February, when experiencing severe chest pain, did he reveal the overdose. Police responded promptly and he was transferred to Dandenong Hospital where he developed acute liver failure and multi-organ failure despite maximal intensive care and N-acetylcysteine. Transfer to Austin Hospital for potential liver transplant was discussed but declined initially due to not meeting transplant criteria; by the time accepted, his condition was grave and no donor liver was available. The coroner found the death not preventable, as the paracetamol ingestion was the fundamental cause. Clinical management was appropriate throughout.

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

Specialties

emergency medicineintensive carehepatologygastroenterologytoxicologyforensic medicine

Drugs involved

paracetamolacetylcysteineglyceryl trinitratevasopressors

Clinical conditions

paracetamol toxicityacute liver failurecoagulopathythrombocytopaeniaacute kidney injurymetabolic acidosismulti-organ failureventricular tachycardiaglobal cardiac dysfunction

Procedures

intubationblood transfusionintensive care support with vasopressors and blood filtration

Contributing factors

  • deliberate ingestion of 90-100 paracetamol tablets
  • delay in disclosure of paracetamol ingestion until 12 hours after remand
  • acute liver failure with severe hepatocellular injury
  • severe coagulopathy and thrombocytopaenia
  • acute kidney injury
  • progressive metabolic acidosis
  • absence of available donor liver for transplantation
  • underlying medical comorbidities: multiple sclerosis, ischaemic heart disease, diabetes

Coroner's recommendations

  1. improved record keeping regarding clinical decision-making processes in inter-hospital transfer discussions, particularly the rationale for initial refusal and subsequent acceptance of patients for potential organ transplantation
  2. consideration of implementation of a single, shared, statewide electronic medical record system capable of recording patient journeys across different hospitals and health services in Victoria to improve care coordination and clinical decision-making visibility
Full text

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