Coronial
WAhospital

Inquest into the Death of Michael Warren DYBALL

Deceased

Michael Warren DYBALL

Demographics

56y, male

Coroner

Coroner Linton

Date of death

2016-05-01

Finding date

2020-06-03

Cause of death

bronchopneumonia complicated by multiorgan failure and hypoxic ischaemic encephalopathy in a man with treated squamous cell carcinoma of the tongue

AI-generated summary

Michael Dyball, a 56-year-old prisoner with chronic kidney disease, hepatitis C, and treated oropharyngeal squamous cell carcinoma, collapsed in his prison cell and suffered cardiopulmonary arrest on 28 April 2016. He died 3 days later from bronchopneumonia complicated by multiorgan failure and hypoxic ischaemic encephalopathy. Expert review concluded his medical care was reasonable and appropriate. The exact precipitant of cardiac arrest was unclear but occurred in context of significant comorbidities. Toxicology revealed unexpected clozapine (not prescribed) but expert opinion indicated this was unlikely contributory. Documentation suggested possible duplicate Aranesp injection recording, but coroner found this was clerical duplication rather than actual double-dosing. Death was natural cause. Care standards were equivalent to community provision.

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

Specialties

nephrologyoncologycardiologyrespiratory medicineemergency medicineintensive carepathologytoxicologycorrectional health

Drugs involved

darbepoetin alfaclozapinediazepamadrenalinevarious antihypertensive and renal management medications

Clinical conditions

chronic kidney disease stage 4end-stage renal failuresquamous cell carcinoma of tongue and tonsilhepatitis Canaemia of chronic kidney diseasehypoxic ischaemic encephalopathybronchopneumoniamulti-organ failurecardiopulmonary arrest

Procedures

tracheostomyPEG tube insertionteeth extractioncardiopulmonary resuscitation

Contributing factors

  • chronic kidney disease stage 4
  • hepatitis C infection
  • advanced oropharyngeal cancer (post-treatment)
  • cardiac comorbidity
  • sudden unexpected collapse in prison cell
  • unclear precipitant for cardiopulmonary arrest
Full text

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