Inquest into the death of Addison Anthony

35y · Male·Active rheumatic pancarditis complicated by pulmonary arterial hypertension, pneumonia and connective tissue disease of unspecified type

A 35-year-old Aboriginal man died from rheumatic pancarditis complicated by pulmonary hypertension, pneumonia and unspecified connective tissue disease. He had presented repeatedly to Katherine Hospital with symptoms suggestive of autoimmune disease but declined hospitalisation due to cultural beliefs about health. While imprisoned, a carbuncle developed which was appropriately treated. Pathology results suggesting autoimmune disorder were noted but not acted upon when he saw a locum doctor. He presented to RDH with respiratory sepsis and received appropriate intensive care treatment, though there were minor delays in care coordination and failure to access his shared electronic health record. Key deficiencies: Correctional Services failed to notify family of critical illness; interpreter services were not available; the shared electronic health record was underutilised; and Katherine Hospital had no system to track incarcerated patients requiring follow-up. While medical treatment was appropriate, system failures prevented optimal care coordination.