Coroner's Finding: DELLATORRE Natale

54y · Male·respiratory failure and acute renal failure due to rhabdomyolysis following trauma

A 54-year-old man with chronic schizophrenia and intellectual disability died from respiratory failure and acute renal failure secondary to rhabdomyolysis following a crush injury to his left thigh sustained while attempting to escape from a psychiatric hospital. He became trapped hanging upside down on a perimeter fence on 19 January 1997. Initial assessment at Royal Adelaide Hospital ED missed early signs of rhabdomyolysis (elevated potassium on blood tests), though the coroner found this was not a serious error given rhabdomyolysis's rarity in isolated thigh injury. Staff at Glenside Hospital provided exemplary monitoring post-injury. Once rhabdomyolysis became established, his death became almost inevitable despite comprehensive ICU management including dialysis, intubation, and tracheostomy. Communication breakdown occurred between ICU staff and family regarding withdrawal of treatment.