WAprison

Inquest into the Death of Anthony Nigel AXTELL

Deceased

Anthony Nigel AXTELL

Demographics

38y, male

Coroner

- Coroner Linton

Date of death

2012-09-13

Finding date

- 20 March 2014

Cause of death

Heart failure in a man with dilated cardiomyopathy and focal severe coronary artery atherosclerosis

AI-generated summary

Anthony Axtell, a 38-year-old man with severe dilated cardiomyopathy from amphetamine use, died of heart failure while in prison custody. Initially treated successfully in 2002 with recovery to normal cardiac function by 2007, he relapsed into amphetamine use from 2007-2012, ceased cardiac medications, and experienced progressive decompensation. Critical clinical issues included: non-compliance with medications during incarceration (June 2012), inconsistent medication dosing and administration records, late recognition of deterioration, and repeated self-discharge against medical advice. Although initial medication prescribing confusion and missed doses occurred, expert cardiologists concluded these did not materially impact outcome given the deceased's prolonged non-compliance from March 2012 onwards. The coroner found care was ultimately appropriate and optimal given the circumstances; however, improved medication recording systems and earlier liaison between prison health and hospital teams could have optimised management.

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

Specialties

cardiologycardiothoracic surgerycorrectional healthintensive careanaesthesia

Error types

medicationsystemcommunication

Drugs involved

amphetamineheroincannabis

Clinical conditions

dilated cardiomyopathyheart failuresevere mitral regurgitationcoronary artery atherosclerosiscardiogenic shockpneumoniapulmonary oedemastroke from cardiac embolusamphetamine-induced cardiomyopathy

Procedures

transoesophageal echocardiographyechocardiographymitraclip procedure (attempted, cancelled)

Contributing factors

Severe dilated cardiomyopathy secondary to amphetamine use
Long-standing non-compliance with cardiac medications from 2007-2012
Relapse into intravenous amphetamine use
Repeated self-discharge against medical advice
Medication administration confusion and missed doses during first period of incarceration (June 2012)
Non-compliance with fluid restriction regime
Limited cardiac reserve and inability to recover after previous episode
Smoking history and continued tobacco use
Reduced eligibility for cardiac transplantation due to substance abuse history

Coroner's recommendations

Staff should be encouraged to make an entry indicating the reason why a medication was not dispensed on Webster pack sheets, as per the legend on the form, rather than leaving spaces blank. This eliminates doubt as to whether medication was dispensed and provides indication of reasons for future reference.
Standard practice should be to request a patient's medical history and records upon admission to prison, consistent with the procedure that occurred on the deceased's second admission on 29 June 2012.

Full text

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