Coronial
WAmental health

Inquest into the Death of Tom FOSKI

Deceased

Tom FOSKI

Demographics

51y, male

Coroner

- Coroner King

Date of death

2012-05-06

Finding date

- 11 April 2014

Cause of death

congestive cardiac failure in association with ischaemic and hypertensive heart disease

AI-generated summary

Tom Foski, a 51-year-old man with chronic schizophrenia, died from congestive cardiac failure associated with ischaemic and hypertensive heart disease. He had multiple medical comorbidities including diabetes, COPD, previous myocardial infarction, and a large untreated abdominal hernia. While at Graylands Hospital, he developed severe polydipsia leading to recurrent hyponatraemia and cardiac decompensation. In late April 2012, he gained over 10kg in two weeks—recorded by nursing staff but not escalated to medical officers. Shortly after commencing diuretics, he collapsed and died. Although care was deemed reasonable overall, the coroner noted a significant weight gain was documented but not communicated to the medical officer. The death was attributed to natural causes with underlying severe cardiac disease.

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

Specialties

psychiatrycardiologygeneral medicine

Error types

communicationdelay

Drugs involved

antipsychotic medicationsdiureticsinsulin

Clinical conditions

chronic schizophreniaparanoid delusionspolydipsiahyponatraemiacongestive cardiac failureischaemic heart diseasehypertensive heart diseasemyocardial infarctionpulmonary oedemapulmonary embolismnon-insulin dependent diabetes mellituschronic obstructive pulmonary diseaseabdominal hernia

Contributing factors

  • chronic polydipsia leading to hyponatraemia
  • severe coronary artery disease
  • uncontrolled fluid intake
  • left ventricular hypertrophy
  • poorly controlled diabetes mellitus
  • heavy smoking causing COPD
  • lack of insight into illness and non-compliance with medication
  • rapid weight gain not escalated to medical team

Coroner's recommendations

  1. Case managers of long-term mental health inpatients whose finances are controlled by the Public Trustee's Office should consult with the Public Trustee with a view to implementing a process of exchange of information to use funds held on behalf of patients to improve their quality of life.
Full text

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