Finding into death of Jeffrey Thomas Wilson
Deceased
Jeffrey Thomas Wilson
Demographics
76y, male
Date of death
2024-12-30
Finding date
2026-02-03
Cause of death
Effects of fire due to home oxygen ignition in the setting of smoking; lung cancer as contributing condition
AI-generated summary
A 76-year-old man with lung cancer and mesothelioma died from thermal injuries sustained when his home oxygen ignited while smoking. He had been discharged on self-funded home oxygen despite a recent smoking history, after the state-funded program (SWEP) deemed him ineligible due to ongoing smoking. Hospital documentation documented continued smoking despite counselling about risks. A prior fire incident on 27 December caused facial burns but did not prompt oxygen supply review or respiratory consultation. The coroner found the death preventable, identifying system failures: no formal guidelines for managing patients requiring home oxygen who don't meet standard criteria, lack of structured risk assessment, and absence of triggered safety reviews following the first fire incident. Process improvements implemented post-death include respiratory specialist involvement in discharge decisions and Hospital in the Home program eligibility criteria requiring six-week smoking cessation or specialist review.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Patient continued smoking despite counselling and recent smoking history
- Discharge on home oxygen without formal prescription documentation
- Lack of formal guidelines for managing home oxygen in patients with recent smoking history
- Absence of structured risk assessment process for private oxygen suppliers
- Prior fire incident on 27 December 2024 did not trigger safety review or oxygen supply reassessment
- No respiratory specialist review documented following first fire incident
- Rigidity of state-funded oxygen program eligibility criteria (six-week cessation requirement) led to use of private suppliers without standardised safety protocols
- Inconsistent follow-up care and risk management
- Patient agency and difficulty with smoking cessation in context of terminal diagnosis
Coroner's recommendations
- Department of Health should consider whether a discharge home oxygen process similar to that instituted by Grampians Health, involving Hospital in the Home and specialist respiratory review, should be recommended as a model of care to other health services
Full text
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