Inquest into the Death of Michael Warren DYBALL

56y · Male·bronchopneumonia complicated by multiorgan failure and hypoxic ischaemic encephalopathy in a man with treated squamous cell carcinoma of the tongue

Michael Dyball, a 56-year-old prisoner with chronic kidney disease, hepatitis C, and treated oropharyngeal squamous cell carcinoma, collapsed in his prison cell and suffered cardiopulmonary arrest on 28 April 2016. He died 3 days later from bronchopneumonia complicated by multiorgan failure and hypoxic ischaemic encephalopathy. Expert review concluded his medical care was reasonable and appropriate. The exact precipitant of cardiac arrest was unclear but occurred in context of significant comorbidities. Toxicology revealed unexpected clozapine (not prescribed) but expert opinion indicated this was unlikely contributory. Documentation suggested possible duplicate Aranesp injection recording, but coroner found this was clerical duplication rather than actual double-dosing. Death was natural cause. Care standards were equivalent to community provision.