Inquest into the Death of Arthur James BONNEY

59y · Male·ischaemic heart disease in the context of acute-on-chronic kidney failure associated with contrast-induced nephropathy

Arthur James Bonney, a 59-year-old prisoner with advanced cardiac disease, chronic kidney disease, and diabetes, underwent a CT scan with iodinated contrast on 30 July 2015 at Fiona Stanley Hospital. Critical failures occurred: his kidney function (eGFR) was not checked on the day of the scan despite being last measured in early June 2015 when it was 29-36; he continued nephrotoxic medications (spironolactone, perindopril, metformin) that should have been stopped; and essential procedures under the hospital's own 2015 guidelines (pre/post-hydration, 48-hour follow-up creatinine testing) were not performed. The scan precipitated contrast-induced nephropathy, acute kidney failure, and likely contributed to fatal cardiogenic shock. The coroner found that contemporary point-of-care eGFR testing and adherence to risk-stratification protocols could have prevented this. FSH has since implemented same-day eGFR testing before contrast administration.