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.
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Specialties
emergency medicineintensive carehepatologygastroenterologytoxicologyforensic medicine
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
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
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
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