CRITICAL INCIDENT AND ANALYSIS PAPER - coroner’s case

FINDING OF INQUEST :  An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 2 nd , 22 nd , 23 rd , 26 th , 27 th , 28 th , 29 th and 30 th days of November 2012, the 17 th day of December 2012, the 27 th , 28 th and 31 st days of May 2013, the 5 th , 6 th , 7 th , 8 th , 25 th , 26 th and 27 th days of November 2013 and the 14 th day of February 2014, by the Coroner’s Court of the said State, constituted of Elizabeth Ann Sheppard, a Coroner for the said State, into the deaths of John William Ryan and Patricia Dawn Walton. The said Court finds that John William Ryan aged 54 years, late of 10 Grandview Court, Crafers, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 2 nd day of April 2008 as a result of hypoxic- ischaemic encephalopathy following ventilatory failure and cardiac arrest in the context of morbid obesity and opiate medication, complicating post-operative recovery from right ankle arthrodesis. The said Court finds that Patricia Dawn Walton aged 66 years, late of 20 Naretha Street, Holden Hill, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 2 nd day of November 2010 as a result of hypoxic- ischaemic encephalopathy following cardiac arrest after developing cardiac syndrome precipitated by myocardial ischaemia as a consequence of uncontrolled hypertension, fluid overload, ongoing pain and coronary artery disease, post left total hip replacement.