Coronial Inquest into the death of Timothy James CHANDLER
Delivered on: 2 August 2019
Delivered at: Perth
Finding of: Coroner Jenkin
Suppression Order: N/A
Summary: At the time of his death, the deceased was an involuntary patient at Fiona Stanley Hospital (the Hospital) because he was the subject of an Inpatient Treatment Order. The deceased died at the Hospital on 25 December 2017 from multiple organ failure and pulmonary thromboemboli complicating generalised sepsis in a man with cellulitis.
On 13 December 2017, the deceased was taken to the Hospital by ambulance. On admission, he complained of a decreasing mobility and increasing weight over the previous seven months and a three week history of testicular pain. The deceased was initially thought to have Fournierâ€™s gangrene, a serious condition requiring anti-biotics and surgery. The deceased had an unconventional belief system and rejected western medicine. As a result, the deceased refused certain medical treatment including CT scans and possible surgery. Given the deceasedâ€™s presentation, it was decided to have him assessed by a psychiatrist to determine if he had capacity to make treatment decisions.
The deceased was reviewed by the Hospitalâ€™s on-call psychiatrist on 14 December 2017. The deceased was found to have a psychotic illness, likely to be delusional disorder or perhaps schizophrenia. On the basis that the deceased did not have the capacity to make treatment decisions, he was placed on an Inpatient Treatment Order and became an involuntary patient.
On 15 December 2017, the deceased was transferred to the acute medical unit at the Hospital. He was found to have heart failure which was thought to be related to fluid overload, rather than a heart attack. He was also diagnosed with long standing right-sided heart damage secondary to sleep apnoea and cellulitis. The deceased was given antibiotics and medications to reduce his fluid overload and prevent a pulmonary embolism.
By 16Â December 2017, the deceasedâ€™s condition seemed to be improving and there was no evidence of pulmonary embolism. However, on 17 December 2017, his condition suddenly deteriorated and his blood pressure became dangerously low. The medical emergency team was called and the deceased was transferred to the intensive care unit. Initially there was some improvement, but he remained in a critical condition and required extensive medical support. On 25Â December 2017, the deceasedâ€™s blood pressure suddenly dropped and despite treatment, could not be stabilised. He subsequently had a cardiac arrest and attempts to resuscitate him were unsuccessful.
The Coroner was satisfied that the supervision, treatment and care provided to the deceased while he was an involuntary patient at the Hospital was both reasonable and appropriate.
Catch Words: Inpatient Treatment Order : Supervision, treatment and care : Natural Causes.
Report: Timothy James CHANDLER