Burrell, Michael Leslie

58y · Male·Multifocal hepatocellular carcinoma due to cirrhosis of the liver due to hepatitis C infection

Michael Leslie Burrell, a 58-year-old prisoner with terminal hepatocellular carcinoma secondary to hepatitis C and cirrhosis, died in the Princess Alexandra Hospital Secure Unit. He was admitted to the ED on 17 September 2016 with nausea, vomiting and abdominal pain. An abdominal x-ray suggested partial bowel obstruction but this was not identified at the time due to the registrar reviewing only one of three images. He was admitted to the Secure Unit where nursing staff noted a persistently elevated heart rate and a 3-point drop in Glasgow Coma Scale score, both meeting criteria for calling a code blue, but this was not done. He deteriorated overnight and was found unresponsive the following morning with signs of massive aspiration. While the underlying disease was terminal and irreversible, the coroner found systemic shortcomings in diagnostic interpretation, adherence to clinical escalation protocols, and the absence of an acute resuscitation plan for a palliative patient. The hospital implemented corrective measures including dedicated code blue communication, staff education, and safety rounds.