Inquest into the Death of Robert William ROMAN

55y · Male·Subdural haematoma in a man with diabetes mellitus and chronic kidney disease (requiring dialysis)

A 55-year-old Aboriginal man with end-stage renal disease, diabetes, ischaemic heart disease and COPD died from a spontaneous subdural haematoma while undergoing haemodialysis in prison custody. He presented with headache during dialysis on 10 May 2018 and rapidly deteriorated with loss of consciousness. Clinical lessons include recognising that spontaneous subdural haematomas can occur in dialysis patients on anticoagulation (aspirin and heparin), though such events are rare and unpredictable. The coroner found appropriate medical care was provided. Key systemic issues identified were: failure to place him on the Terminally Ill List upon admission despite complex health needs; delayed family notification of clinical deterioration (approximately 2-3 hours); and only one next-of-kin recorded despite protocol requiring at least two. No clinical errors were identified in the acute management. Improvements recommended include proactive identification of suitable patients for the Terminally Ill List, ensuring multiple next-of-kin contacts are recorded, and establishing earlier notification protocols for prisoner health deterioration.