Inquest into the Deaths of Di Biase, Andre Josef and Dodd, Bryan Jeffrey

AI-generated summary

Bryan Jeffrey Dodd, a 61-year-old man with metastatic colorectal cancer, was admitted to Royal Perth Hospital in September 2023 for acute pain management. Severe, unmanageable pain led him to escalate use of oxycodone and medicinal cannabis beyond therapeutic levels; this medication overuse resulted in delirium and confusion, making it unsafe to discharge him. He experienced two Code Black emergencies within 24 hours due to agitation and attempted window breakage. When transferred to Ward 9A on the evening of 15 September 2023, neither the behavioral escalation history nor the prior Code Black incidents were communicated in the handover. While delirious and confused, attempting to return home, Dodd broke the annealed glass window in his room—the same easily-breakable glass that another patient had broken four months earlier—and fell from the ninth-floor balcony. The coroner found his death accidental rather than intentional, with clinical management appropriate. However, systemic failures were evident: the annealed windows had not been upgraded to safety glass after the prior death, despite eight weeks having been sufficient for a similar upgrade elsewhere; the handover failed to communicate risk factors that should have triggered allocation of a personal duress alarm to his one-to-one carer; and the same environmental hazard that killed the first patient remained unaddressed, resulting in a second tragedy.

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