Coroner's Finding: SCHACHE Leon John

47y · Male·acute subarachnoid haemorrhage with contributing ruptured saccular aneurysm of the basilar artery

A 47-year-old male remand prisoner died from acute subarachnoid haemorrhage due to a ruptured basilar artery aneurysm while in custody at Adelaide Remand Centre. He presented with headache and dizziness on 6 November 2017, received paracetamol and ibuprofen, and was found unresponsive the following morning. The coroner found his care and treatment appropriate and the death was the result of an unexpected natural event (aneurysm rupture). No clinical errors or preventability concerns were identified. A minor resuscitation delay occurred when the first defibrillator was flat, requiring approximately one minute to locate a second device.