Inquest into the Death of Seth Gregory Victor YEEDA
Deceased
Seth Gregory Victor YEEDA
Demographics
19y, male
Coroner
State coroner Fogliani
Date of death
2018-05-03
Finding date
2022-07-20
Cause of death
Rheumatic heart disease (severe aortic valve regurgitation)
AI-generated summary
Seth Yeeda, 19-year-old Aboriginal male with rheumatic heart disease from childhood, died in custody from severe aortic valve regurgitation. He had required aortic valve replacement surgery since 2014. In December 2017, while imprisoned, his doctor (Dr Todd) referred him urgently to cardiology. This referral was not progressed due to a service transition from WA Cardiology to Perth Cardiovascular Institute, coupled with lack of referral tracking systems. Yeeda died five months later during basketball exercise. The coroner found his death likely preventable had he undergone recommended heart valve surgery. Contributing factors included poor service transition planning, failure to communicate confidentiality concerns, absence of robust referral tracking systems, and premature removal of alerts preventing vigorous exercise. No adverse findings against individual clinicians, but systemic failures identified in inter-agency coordination and referral management processes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- Failure to progress cardiology referral despite urgent priority rating
- Service transition from WA Cardiology to Perth Cardiovascular Institute without adequate handover
- WA Cardiology's refusal to share Wait List information citing confidentiality concerns
- Lack of communication of confidentiality concerns to service commissioners
- Absence of robust referral tracking system in Department of Justice
- Referral not recorded on Problem List in medical records
- Removal of Alert preventing vigorous exercise without doctor consultation
- No in-reach specialist cardiology services at prison
- Vigorous basketball exercise shortly before collapse
- Inadequate system integration between Department of Justice and WACHS
Coroner's recommendations
- Department of Justice and WACHS consider working together to facilitate provision of information concerning status of external referrals and outcomes of external appointments to enable progression of Referral Tracking System, addressing confidentiality issues
- Department of Justice allocate sufficient resources to establish project team to finalise work on Referral Tracking System, supporting earlier recommendation from Scott inquest
- Department of Justice consider feasibility of making list available to custodial officers outlining Alerts as to unfitness for sport or work, addressing confidentiality issues and providing guidance on purpose and expected response to such Alerts
Full text
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