Coroner's Court of Western Australia

Inquest into the Death of Wlodzimierz DUDEK

Inquest into the Death of Wlodzimierz DUDEK

Delivered on :19 September 2018

Delivered at : Perth

Finding of : Coroner King

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was an inpatient on a treatment order under the Mental Health Act 2014 residing at Graylands Hospital at the time of his death.

The deceased was 35 years old when he had his first major depressive episode. He was subsequently diagnosed with bipolar affective disorder. From that time, he had predominantly manic relapses with psychosis, often prolonged, and was admitted to several mental health hospitals.

While in the mental health unit at Joondalup Health Campus in December 2015, the deceased developed pneumonia, possibly due to ischaemic heart disease. His condition deteriorated suddenly on 9 December 2015, with elevated and irregular pulse rate and elevated blood pressure. He recovered from the pneumonia, but on 14 December 2015 a speech pathologist noted mild to moderate oropharyngeal dysphagia (difficulty swallowing) likely to related to delirium and recommended a soft food diet. There had been no previous reports of dysphagia.

The deceased was transferred to Graylands Hospital on 5 April 2016. By that time, his respiratory symptoms had resolved completely and his medical problems had been stable for months. The discharge summary from Joondalup Health Campus did not mention dysphagia. In mid-July 2016, he was struck in the face by another patient and was moved to Casson Ward, which catered for patients with significant physical co-morbidities. In August 2016 another patient in Casson Ward struck the deceased in the face and the deceased was placed on a 2:1 special, whereby he was monitored by two staff members for his and other patients’ protection.

On 4 October 2016 the deceased was eating breakfast on his own when he choked on bread, became unconscious and his heart arrested. Hospital staff at Graylands Hospital administered CPR and ambulance officers took him to Sir Charles Gairdner Hospital, where he was admitted into the intensive care unit with a suspected hypoxic brain injury. His condition deteriorated and on 7 October 2016, following meetings between ICU medical staff and the deceased’s family and a subsequent discussion between staff and the Public Guardian, the deceased was extubated and provided with palliative care until he died shortly thereafter.

The Coroner was satisfied that the supervision, treatment and care provided to the deceased was reasonable and appropriate.

Catch Words : Graylands : Dysphagia : Aspiration of food (Choking) : Mental Health : Accident.


Last updated: 4-Oct-2018

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