Finding into death of Keanne Liza Whittam

43y · Female·Hypoxic ischaemic encephalopathy secondary to out of hospital cardiac arrest due to ischaemic heart disease

43-year-old woman with severe, undiscovered coronary artery atherosclerosis died from out-of-hospital cardiac arrest while in police custody at Dame Phyllis Frost Centre. She had presented to ED 5 months earlier with leg ulcers but was not screened for cardiac disease despite risk factors (smoking, intravenous drug use). No cardiac murmur was documented, and she had no known cardiac history. She was arrested for drug trafficking and died during her first night in custody while withdrawing from heroin. Autopsy revealed extensive coronary blockages far exceeding expected for age 43. Clinical staff at police station, prison, and hospitals managed her care appropriately given available information. The death was preventable only if prior screening had detected undiagnosed severe coronary disease.