Deceased
Lewis Walter WARD
Demographics
33y, male
Coroner
Acting State Coroner Sarah Linton
Date of death
2023-07-25
Finding date
2026-01-08
Cause of death
Complications of out of hospital cardiac arrest in a man with atherosclerotic cardiovascular disease and diabetes mellitus
AI-generated summary
A 33-year-old Indigenous man with Type 2 diabetes, hypertension and dyslipidemia collapsed while playing football in a prison in July 2023, sustaining an out-of-hospital cardiac arrest from which he did not recover. Autopsy revealed severe atherosclerotic coronary artery disease with evidence of at least two prior myocardial infarctions. He had been appropriately referred for cardiology investigation (exercise stress test) in October 2021 after ECGs showed changes suggesting prior inferior MI, with an appointment scheduled February 2022. However, due to communication errors, the appointment was missed, incorrectly marked as attended, and not rescheduled until July 2023—three days after his fatal collapse. Expert cardiology opinion indicated earlier testing may have identified ischaemic disease warranting further investigation, but whether this would have prevented his death remains speculative. The Department of Justice and WACHS have since implemented improved referral tracking systems to prevent recurrence.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
24y · Male·Cardiac arrest in a man with Sotos syndrome and multiple comorbidities, includin…
Joshua Fredrik Van Malssen, a 24-year-old man with Sotos syndrome, complex cardiac disease, asthma, and obesity, died from cardiac arrest after being restrained in the prone position during a lawful arrest by Public Tran…
58y · Male·complications of oesophageal cancer, with terminal palliative care
Stephen Joseph Schipp, a 58-year-old sentenced prisoner, died from complications of oesophageal cancer with terminal palliative care at Bunbury Regional Hospital. He had been diagnosed with oesophageal carcinoma in Janua…
45y · Male·atherosclerotic heart disease
Lex Gregory Maher, a 45-year-old Aboriginal man imprisoned at Greenough Regional Prison, died of atherosclerotic heart disease while playing basketball. He had abnormal ECGs detected in March and May 2022 and was appropr…
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