Deceased
Siauto Eliuta Tunumafono
Demographics
43y, female
Coroner
Coroner P.J. Morrison
Date of death
2013-12-11
Finding date
2018-11-29
Cause of death
cardiac arrhythmia (unascertained), probably fatal cardiac dysrhythmia
AI-generated summary
A 43-year-old woman collapsed at home and was found in cardiac arrest after 20-25 minutes. Ambulance arrived and recognised ventricular fibrillation but failed to defibrillate for approximately 20 minutes, despite protocol indicating it was indicated at 9 minutes post-arrest. Errors in treatment resulted from lack of written defibrillation protocols, incompatible defibrillators between fire and ambulance services, and confusing device prompts. Expert review concluded the delay in defibrillation was unlikely to have contributed to death due to prolonged collapse duration before treatment. The coroner found systemic failures rather than individual clinician error and identified the absence of written protocols as a public safety matter. Subsequent improvements included compatible defibrillator pads, device reconfiguration, new handover protocols, and enhanced staff training.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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