Deceased
Raymond Sydney CHEEK
Demographics
89y, male
Coroner
Coroner Urquhart
Date of death
2021-09-19
Finding date
2024-09-24
Cause of death
Complications in association with a gastrointestinal illness in an elderly man with diabetes mellitus, chronic liver disease and atherosclerotic heart disease, medically palliated
AI-generated summary
Raymond Sydney Cheek, an 89-year-old prisoner with multiple comorbidities including insulin-dependent diabetes, died from complications of gastrointestinal illness with acute renal failure. While medical care at Casuarina Prison was generally appropriate, there was one medication error: an 18-unit insulin dose administered instead of the prescribed 9 units on 11 September 2021. Expert endocrinology review confirmed this error did not contribute to his death. The critical failure was the unjustified use of restraints during his final hospitalisation despite policy clearly prohibiting restraints for elderly, frail, terminally ill prisoners without risk assessment. No risk assessment was completed before transfer to hospital. Restraints remained for 7 days until his death, violating dignity and policy. Hospital care was appropriate given his grave condition. The Department has subsequently implemented improvements in diabetes monitoring and restraint protocols.
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
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58y · Male·Hypertensive and valvular heart disease
Kevin McCracken, 58, died of hypertensive and valvular heart disease following sudden cardiac collapse in a prison pre-release unit. He had complex pre-existing cardiac disease including previous valve replacement and ao…
61y · Male·metastatic oesophageal neuroendocrine carcinoma
Terrence Wells, a 61-year-old prisoner, died from metastatic oesophageal neuroendocrine carcinoma in December 2018. Cancer was diagnosed in April 2018 after he reported difficulty swallowing, which was initially attribut…
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