Coronial
WAhospital

Inquest into the Death of Eric WUMBIE

Deceased

Eric WUMBIE

Demographics

37y, male

Coroner

Coroner Jenkin

Date of death

2016-04-13

Finding date

2020-02-20

Cause of death

valvular and ischaemic heart disease

AI-generated summary

Eric Wumbie, a 37-year-old Aboriginal male prisoner, died from valvular and ischaemic heart disease on 13 April 2016 following intraoperative cardiac arrest during planned cardiothoracic surgery at Fiona Stanley Hospital. He had severe aortic regurgitation, left ventricular failure, and coronary artery stenosis diagnosed only three weeks before death. Although his condition developed over 3-5 years and featured a subtle cardiac murmur easily missed on routine examination, cardiac screening was appropriately withheld in the absence of symptoms. The Coroner found high-quality hospital care and appropriate prison management. However, systemic failures included: (1) lack of documentation regarding prisoner notification to next-of-kin despite policy requirements; and (2) absence of discharge summary transmission between Derby and Broome Hospitals potentially contributing to diagnostic delay. The death was not preventable given the acute nature of the final presentation, but improved information transfer protocols could enhance future prisoner healthcare coordination.

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

Specialties

cardiologycardiothoracic surgerycorrectional healthemergency medicine

Error types

systemcommunication

Clinical conditions

congestive cardiac failureaortic regurgitationleft ventricular failurecoronary artery stenosisventricular fibrillationcardiac arrestpericardial adhesions

Procedures

coronary artery bypass surgeryaortic valve replacementBentall procedurelaparotomycardiopulmonary bypasspericardial dissection

Contributing factors

  • severe aortic regurgitation with dilated ascending aorta
  • severe left ventricular failure with ejection fraction of 30%
  • severe coronary artery stenosis
  • pericardial adhesions discovered intraoperatively
  • long-standing cardiac disease undetected for 3-5 years prior to presentation
  • failure to contact next-of-kin in accordance with departmental policy
  • delayed transmission of discharge summaries between hospitals

Coroner's recommendations

  1. Department of Justice to make every effort to comply with Policy Directive 82 requirements and contact next-of-kin of prisoners admitted to hospital
  2. Documentation of next-of-kin contact efforts should be clearly recorded on the Total Offender Management Solution (TOMS) database
  3. Implement electronic transmission of hospital discharge summaries to automatically import into prisoner medical records
Full text

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