Coroner's Finding: WALPOLE Gary Frederick

49y · Male·small intestinal infarction due to mesenteric and portal vein thrombosis associated with polycythaemia rubra vera

Gary Walpole, a 49-year-old teacher with polycythaemia rubra vera, died from small intestinal infarction due to mesenteric and portal vein thrombosis. He was admitted to Royal Adelaide Hospital with oesophageal varices from portal hypertension, treated with endoscopic banding. On 19 October 2003, he became delirious and agitated, leading to involuntary detention under the Mental Health Act. He was found unresponsive at 6:15am and died despite resuscitation. The coroner found his clinical treatment timely and appropriate. The forensic pathologist noted treatment of this condition is exceptionally difficult—anticoagulation risks haemorrhage while haemostasis allows thrombosis progression. No preventable errors were identified, though the family raised concerns about communication and lack of notification during his final agitated episode.