Coronial
WAhospital

Inquest into the Death of Delray BEASLEY

Deceased

Delray BEASLEY

Demographics

56y, male

Date of death

2010-06-14

Finding date

- 8 July 2014

Cause of death

unascertainable; complications of liver cirrhosis and/or exposure most likely

AI-generated summary

Delray Beasley, a 56-year-old Aboriginal man with chronic liver cirrhosis from longstanding alcohol abuse, was admitted to Kalgoorlie Hospital in May 2010 following an alleged assault. He was initially evaluated for possible head injury but imaging ruled out significant intracranial pathology. His confusion and neurological symptoms were attributed to alcohol withdrawal and liver disease rather than head injury. By 14 June, he was medically cleared for discharge, though formal arrangements were pending. That evening he left the ward unannounced due to noise disturbance, taking hospital bedding but leaving an intravenous cannula in place. Hospital staff appropriately notified family and police. He was found deceased in bushland on 10 July. Autopsy revealed advanced liver cirrhosis but no definitive cause of death; complications of liver disease or exposure were likely. The coroner noted the case highlights the challenges of managing self-discharging patients with complex social circumstances and the value of formalised missing person procedures in hospitals.

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

Specialties

emergency medicineneurosurgeryneurologygeneral medicineinfectious diseasesforensic medicine

Error types

system

Drugs involved

diazepamdesmethyldiazepam

Clinical conditions

cirrhosis of the liverportal hypertensionoesophageal varicesalcoholic liver diseasealcohol withdrawal syndromefacial lacerationdepressed nasal fracturechronic anaemiamacrocytosisthrombocytopeniahypothermia/exposure

Procedures

CT scan of headCT scan of braincervical spine x-raysblood testpost-mortem examinationtoxicology analysis

Contributing factors

  • chronic severe liver disease from chronic alcohol abuse
  • alcohol withdrawal syndrome
  • neurological symptoms initially attributed to head injury but more likely from alcohol withdrawal and liver disease
  • self-discharge from hospital without formal medical clearance
  • inadequate discharge arrangements for non-local patient
  • patient left hospital with IV cannula still in situ
  • exposure to cold outdoor conditions
  • unknown circumstances and location of deceased after leaving hospital

Coroner's recommendations

  1. WA Country Health Service should give consideration to developing a standardised procedure for patients absconding from hospital, similar to the formalised Discharge Against Medical Advice Policy already in place, given that the current formalised missing persons procedure at Kalgoorlie Regional Hospital appears to be hospital-specific
  2. Kalgoorlie Regional Hospital's formalised missing persons procedure requiring completion of a notification form providing clarity on patient circumstances, level of risk, and notification status is commended and should serve as a model
Full text
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