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Inquest into the Death of Mary Josephine Van der WALT

Deceased

Mary Josephine Van der WALT

Demographics

28y, female

Coroner

Coroner King

Date of death

2014-04-23

Finding date

2017-09-15

Cause of death

ligature compression of the neck

AI-generated summary

Mary Van Der Walt, a 28-year-old with depression, anxiety, and borderline personality disorder, died by hanging on 21 April 2014. Two police officers responding to her initial '000' call found her unresponsive and pulseless. They determined she was dead based on absent pulse and non-reactive pupils, so did not commence CPR. Paramedics arrived 6 minutes later, initiated CPR and adrenaline, and restored circulation after 15 minutes. However, she had suffered irreversible hypoxic brain injury and died 2 days later. The coroner found the officers' decision understandable given their training emphasised pulse-checking to confirm death before attempting CPR. Key clinical lessons: modern resuscitation guidelines recommend CPR for all unresponsive, non-breathing patients regardless of pulse; pulse palpation is unreliable and should not guide CPR decisions; early CPR initiation significantly improves survival outcomes; and bystander/first responder CPR can be life-saving even when outcome ultimately poor.

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

Specialties

emergency medicineintensive carepsychiatrypsychologyparamedicine

Error types

diagnosticcommunicationsystem

Drugs involved

desvenlafaxinedesvenlafaxineadrenaline

Clinical conditions

suicide by hangingcardiac arrestasystolehypoxic brain injuryhypoxic ischaemic encephalopathycerebral oedemaneurogenic pulmonary oedemadepressionanxietyborderline personality disordersuicidal ideation

Contributing factors

  • delay in commencing CPR by police officers
  • police training emphasising pulse-checking before CPR initiation
  • assumption by police officers that deceased had been dead for some time based on 'sudden death' CAD classification
  • mental illness - depression, anxiety, borderline personality disorder
  • psychosocial stressors

Coroner's recommendations

  1. The deceased's case should be used as a case study in police training to reinforce the dangers of relying on assumptions about patient status based on dispatch information
  2. Police training should be updated to apply the DRS ABCD resuscitation model to all unconscious casualties irrespective of the apparent cause of unconsciousness
  3. All operational police officers should undergo the updated first aid refresher course
  4. Western Australia Police and the Government should equip police vehicles with automated external defibrillators (AEDs) at the earliest opportunity to improve out-of-hospital cardiac arrest survival rates
Full text
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Source and disclaimer

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