Coroner's Finding: JAMES Kevin

70y · Male·spontaneous left frontal intracerebral haemorrhage

A 70-year-old man incarcerated at Yatala Labour Prison died from spontaneous left frontal intracerebral haemorrhage at Modbury Hospital. He had pre-existing chronic obstructive pulmonary disease, severe interstitial lung disease, and osteoporosis. In September 1998, he suffered a stroke and was appropriately transferred to hospital and recovered. In September, erratic behaviour prompted referral to hospital where he collapsed and seized. He was intubated with initial diagnosis of COPD exacerbation with hypoxic seizure and respiratory arrest. Subsequent investigations revealed anterior myocardial infarction and recent CVA. A tracheostomy was performed. EEG showed diffuse hypoxic brain injury with poor prognosis. Aggressive management was ceased in consultation with family. He developed pneumonia and septicaemia, ultimately suffering fatal respiratory and cardiac arrest. The coroner found appropriate detection, treatment, and transfer at each stage with no grounds for criticism.