Coronial
WAhospital

Inquest into the Death of Michael John Herrick

Deceased

Michael John Herrick

Demographics

44y, male

Date of death

2003-05-17

Finding date

2004-07-19

Cause of death

cardiac arrhythmia in a man with liver failure due to cirrhosis and focal coronary arteriosclerosis

AI-generated summary

Michael John Herrick, a 44-year-old prisoner with end-stage liver cirrhosis secondary to hepatitis C and alcohol abuse, died from cardiac arrhythmia at Sir Charles Gairdner Hospital. He had been receiving aggressive treatment for his advanced liver disease, which was complicated by cardiac failure and hepatic encephalopathy. The coroner found the death resulted from natural causes and that the quality of supervision, treatment, and care while in custody was of high standard. However, the coroner raised significant concerns about the 'Not for Cardiopulmonary Resuscitation' form process at Sir Charles Gairdner Hospital. The forms lacked patient signature despite the deceased being capable of signing, and consultation with the consultant gastroenterologist was not documented. The coroner made recommendations to improve the form's completion and implementation, including requiring consultant and patient signatures, specifying review dates, and clarifying when forms should be voided.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

gastroenterologygeneral medicineintensive careanaesthesia

Error types

communicationprocedural

Drugs involved

caffeinetheophylline

Clinical conditions

cirrhosisliver failurehepatitis Ccardiac arrhythmiacoronary arteriosclerosiscardiac failurehepatic encephalopathyorganic brain syndrome

Procedures

cardiopulmonary resuscitationintubationdefibrillation

Contributing factors

  • end-stage liver disease secondary to hepatitis C and chronic alcohol abuse
  • cardiac failure and cardiac disease with coronary arteriosclerosis
  • high caffeine levels possibly related to hepatic dysfunction
  • hepatic encephalopathy

Coroner's recommendations

  1. The 'Not for Cardiopulmonary Resuscitation' forms at Sir Charles Gairdner Hospital should be redrafted to ensure they are signed by both the consultant and registrar treating the patient
  2. The forms should be signed by the patient if the patient is able to sign
  3. All forms should have a specified review date
  4. Forms should be void in the event of a significant change in circumstances such as discharge from hospital or availability of an organ transplant
  5. The consultant responsible for the decision should sign the form to provide protection for the registrar and clear evidence of consultant approval
  6. Patient signature requirements should use clear language such as 'if able' rather than ambiguous terms like 'if applicable' or 'if appropriate'
  7. Important instructions regarding when patient signatures should be obtained should be available on the form itself
Full text
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