Coroner's Finding: Leane, Stewart Anthony

62y · Male·end stage renal failure complicating oxalate crystal nephropathy with contributing head injury

Stewart Anthony Leane, 62, died from end-stage renal failure due to oxalate crystal nephropathy with contributing head injury. He had complex medical needs including dialysis-dependent kidney failure, schizophrenia, and recent head trauma from falls. After two falls within days in July 2021, he sustained a brain injury and exhibited increasingly challenging behaviour (pulling dialysis lines, absconding, aggression). A guardianship order with special powers was obtained. Dialysis was withdrawn on 24 August with transition to palliative care, and he died 5 days later. The coroner found the standard of care at both Mount Barker Hospital and Royal Adelaide Hospital appropriate, and made no recommendations. The case highlights the complexity of managing patients with multiple comorbidities, behavioural changes post-head injury, and end-of-life decision-making in the context of declining renal function.