Coroner's Finding: GRAEFE Phillip Brian

62y · Male·Multi-organ failure due to paraquat ingestion

A 62-year-old man with diabetes, renal failure, and hypertension died from multi-organ failure following intentional ingestion of approximately 100-150ml of paraquat. He had recently assumed sole responsibility for the family farm after his father's admission to permanent care. He telephoned his brother-in-law reporting suicidal ideation, was found semi-conscious with characteristic blue discoloration, and was transported to hospital. An Inpatient Treatment Order was made at Kimba Hospital. Despite appropriate emergency management including earth therapy en route, intubation, mechanical ventilation, and activated charcoal administration at the Queen Elizabeth Hospital, the ingested dose (160mg/L blood concentration) was fatal. The coroner found no medical intervention could have prevented death and that appropriate care was provided at both hospitals.