Coroner's Finding: STEAD Kenneth Alfred

79y · Male·delirium due to aspiration pneumonia complicating advanced metastatic non-small cell lung cancer (stage 4)

A 79-year-old man with metastatic lung cancer suffered multiple strokes causing confusion and behavioural disturbance. He was detained under Mental Health Act. On the night shift, nursing staff found him unresponsive and pulseless but failed to call a Code Blue or commence resuscitation despite a documented full resuscitation order. The on-call doctor appropriately instructed Code Blue activation when reached, but the patient was already deceased for several minutes. The coroner found the failure to call Code Blue breached hospital protocol but made no difference to outcome, as the patient was irreversibly dead when discovered. Key lessons include ensuring clear communication between nursing staff during acute deterioration, adhering to resuscitation protocols regardless of perceived prognosis, and seeking senior guidance promptly when uncertain.