Inquest into the death of Malouvailoa Tafau

20y · Male·cardiac arrest due to complications of infective endocarditis against a background of rheumatic heart disease

Maluovailoa Tafau, a 20-year-old man in custody, died from cardiac arrest due to infective endocarditis complicated by rheumatic heart disease. He had submitted two patient self-referral forms (September 2016 and February 2017) reporting chest pain, fever and weight loss—cardinal signs of endocarditis—but Justice Health clinicians failed to assess him despite policy requiring urgent evaluation for chest pain. A missed opportunity to diagnose and treat endocarditis in February 2017 likely contributed to his death two months later. Earlier investigation and antibiotic therapy would probably have prevented the fatal coronary embolus. Key clinical lessons: respond promptly to custodial patient self-referrals, particularly for chest pain and fever; maintain accessible electronic health records; ensure systemic follow-up when patients fail to attend; and recognise that endocarditis presents with non-specific symptoms (fever, lethargy, weight loss) in a patient with pre-existing cardiac risk (heart murmur).