Deceased
Russell David BROCKLISS
Demographics
38y, male
Coroner
Deputy State Coroner Linton
Date of death
2019-06-08
Finding date
2021-10-22
Cause of death
acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclerosis and elevated body mass index (obesity); schizoaffective disorder was a significant contributing factor
AI-generated summary
Russell Brockliss, a 38-year-old Aboriginal man with severe treatment-resistant schizoaffective disorder and significant cardiovascular risk factors (obesity, smoking, focal coronary atherosclerosis), died from acute cardiac arrhythmia while in mental health involuntary care. He was admitted to the High Dependency Unit after a relapse on 7 June 2019 and discovered unresponsive the following morning. Evidence suggests he died several hours before discovery, possibly around 7am. Critical clinical lessons include: inadequate physical health monitoring despite documented low oxygen saturations and high-risk cardiac status; a missed opportunity to perform pulmonary function testing during his April-May 2019 admission; failure to obtain physical observations on the evening of 7 June when the patient had calmed; and missing observation charts from midnight onwards that prevent assessment of his final hours. The coroner highlighted gaps in visual observation protocols, particularly difficulty assessing breathing through windows of sleeping patients. Though staff generally followed existing procedures, changes have since been implemented including mandatory pair entry for sleeping patient checks, better MET call infrastructure, and simulation training for resuscitation responses.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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