Inquest into the death of Clifford Deas

64y · Male·Arteriosclerotic coronary artery and hypertensive heart disease

Clifford Deas, a 64-year-old man in custody at Long Bay Hospital Correctional Centre since December 2015, died on 5 March 2016 from arteriosclerotic coronary artery disease and hypertensive heart disease, with end-stage renal failure as a contributing factor. He had complex medical comorbidities including emphysema, previous myocardial infarction, and dialysis dependence. Critical clinical lessons include: his severe fluid overload and non-compliance with dialysis (completing only 1.5 of 5 scheduled hours on 2 March, then 20kg overweight on 3 March) suggested inadequate monitoring or intervention for acute decompensation; his acute collapse on 12:30pm on 5 March warranted clinical assessment and possible escalation; the absence of active warning signs between collapse and final cardiac event represented a missed opportunity for clinical intervention; and inadequate capacity to detect and respond to acute deterioration in a custodial setting with high-acuity medical needs.