Finding into death of David James Dorling

59y · Male·multiorgan failure complicating paracetamol toxicity

David James Dorling, a 59-year-old man with multiple sclerosis, ischaemic heart disease, and diabetes, ingested 90-100 paracetamol tablets on 1 February 2024 with suicidal intent. He attended court the next day and was remanded in custody without disclosing the ingestion. He developed symptoms (vomiting, chest pain, dizziness) during transport and police custody but attributed them to benign causes. Only at midnight on 3 February, when experiencing severe chest pain, did he reveal the overdose. Police responded promptly and he was transferred to Dandenong Hospital where he developed acute liver failure and multi-organ failure despite maximal intensive care and N-acetylcysteine. Transfer to Austin Hospital for potential liver transplant was discussed but declined initially due to not meeting transplant criteria; by the time accepted, his condition was grave and no donor liver was available. The coroner found the death not preventable, as the paracetamol ingestion was the fundamental cause. Clinical management was appropriate throughout.