Coronial
ACTcommunity

AN INQUEST INTO THE DEATH OFELFRIEDE ADELE TREMETHICK

Deceased

Elfriede Adele Tremethick

Demographics

85y, female

Coroner

Coroner P.J. Morrison

Date of death

2016-10-21

Finding date

2018-02-27

Cause of death

acute exacerbation of congestive heart failure, following injuries suffered in a fall

AI-generated summary

Ms Tremethick, an 85-year-old with congestive heart failure, fell at home and suffered a lacerated forearm. Paramedics attended and initially administered methoxyflurane for pain relief. She developed fulminant pulmonary oedema and aspirated gastric contents during cardiorespiratory arrest. The coroner found she died from acute exacerbation of congestive heart failure following her fall. While expert review identified suboptimal paramedic care (limited initial assessment, ineffective communication, failure to attempt advanced airway management), the expert opinion concluded these deficiencies unlikely contributed to her death. The primary cause was her cardiac deterioration triggered by her fall and positioning, with aspiration occurring as a terminal event rather than primary cause. ACTAS had already undertaken remedial training and policy reviews.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicineparamedicinecardiologyforensic medicine

Error types

proceduralcommunication

Drugs involved

methoxyflurane

Clinical conditions

congestive heart failureleft ventricular hypertrophyacute pulmonary oedemaaspirationcardiorespiratory arrest

Procedures

cardiopulmonary resuscitationmanual ventilation

Contributing factors

  • left ventricular hypertrophy
  • fall with head-down positioning increasing venous return
  • pain and stress from fall injury
  • possible contributory effect of methoxyflurane on cardiorespiratory function
  • aspiration of gastric contents as terminal event

Coroner's recommendations

  1. Key topics to be covered in paramedic clinical in-service training including cardiac arrest management, teamwork and communication, and advanced airway management with simulation exercises
  2. Review and update of ACTAS policy on termination of resuscitation and management of deceased persons to reinforce when paramedics should cease resuscitation and that urgent transport is not warranted after patient death
  3. Systemic review of airway management practices for consideration by ACTAS Clinical Advisory Committee, reiterating importance of placing advanced airway in cardiac arrest patients
Full text
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