Inquest into the Death of Daniel Josef ADWENT
Deceased
Daniel Josef ADWENT
Demographics
44y, male
Date of death
2015-03-21
Finding date
2019-05-13
Cause of death
gunshot wound to abdomen
AI-generated summary
A 44-year-old male died from a gunshot wound to the abdomen sustained during a police response to a domestic violence incident. He became aggressive, wielded a knife, and lunged at police after Taser and pepper spray failed. The officer shot him in self-defence. Medical treatment at Fiona Stanley Hospital involved extensive resuscitative efforts including thoracotomy, laparotomy, and interventional radiology. Critical clinical lessons include: delayed notification of consultant surgeons (general and cardiothoracic) who could have provided essential expertise; the deceased's unrecognized inferior vena cava tear caused ongoing bleeding that packing and embolisation could not control; and the severity and duration of cardiac arrest (approximately 1 hour) made survival highly unlikely (1-5% estimated). Hospital policies were subsequently amended to ensure early consultant notification for major trauma patients, and improved training protocols for resuscitative procedures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- delayed notification to consultant general surgeon
- delayed notification to consultant cardiothoracic surgeon
- failure to explore retroperitoneal haematoma
- unidentified inferior vena cava tear
- prolonged cardiac arrest prior to hospital arrival (approximately 20 minutes)
- severe shock and coagulopathy
- multiple unrecognised injuries (pancreatic head avulsion, duodenal transection)
- non-surgical fellow performing initial resuscitative procedures without senior consultant present
Coroner's recommendations
- Notification of appropriate consultants: Fiona Stanley Hospital has amended its Trauma Activation Response Policy to provide early notification of on-call general surgical and cardiothoracic consultants when a Priority 1 trauma patient with penetrating chest injury is being transported
- Training in resuscitative thoracotomies: Fiona Stanley Hospital to design Emergency Medicine education sessions on resuscitative thoracotomy emphasising removal of Lucas device prior to commencing procedure
- Credentialing of Royal Perth Hospital trauma surgeons: Fiona Stanley Hospital to credential major trauma service surgeons from Royal Perth Hospital to enable their attendance and assistance at Fiona Stanley Hospital when required
- Consultation and escalation: Implementation of formal policy requiring persistence in contacting consultants for urgent cases, with escalation to duty medical director if initial attempts unsuccessful
- Procedural training: Training of acute surgical unit and general surgical consultants and fellows to perform resuscitative thoracotomy including aortic clamping skills where appropriate
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