Inquest into the death of Freddie Peterson

30y · Male·diffuse alveolar damage, a complication of bacterial endocarditis

Freddie Peterson, a 30-year-old Aboriginal man from Papunya, died in custody from bacterial endocarditis complicated by diffuse alveolar damage. He was imprisoned for nine months and presented to the prison medical centre on 24 June 2005 with acute left-sided pain and inability to move his legs. Hospital evaluation revealed bacterial endocarditis affecting his heart valve with septic emboli to multiple organs including brain, spleen, and kidneys. The coroner found no deficiency in his care or supervision. Key clinical learning: bacterial endocarditis can present acutely and progress rapidly; his underlying poor health from chronic alcoholism, diabetes, chronic pancreatitis, and coronary atherosclerosis created vulnerability to overwhelming infection. The coroner accepted the decision not to commence diabetes medication was the deceased's own informed choice and did not contribute to his death.