Coroner's Finding: ADAMS Debra Louise

52y · Female·hepatic encephalopathy due to Child C cirrhosis of the liver on a background of alcohol abuse, diabetes and hepatitis C

A 52-year-old woman with chronic liver disease from alcohol abuse, diabetes and hepatitis C died from hepatic encephalopathy and cirrhosis. She presented to Port Pirie Medical Centre with bleeding, pain and confusion. Blood tests revealed severe anaemia and liver disease; imaging showed chronic pancreatitis. She was transferred to Royal Adelaide Hospital where she was placed on a Mental Health Act inpatient treatment order due to confusion and inability to consent to treatment. A psychiatrist confirmed the order was appropriate given her severe medical decompensation. The patient was reviewed by MET and ICU teams. The coroner found the care provided at both facilities was appropriate with no identified deficiencies. The death resulted from her underlying medical condition rather than any clinical error or system failure.