Inquest into the death of Dr Peter Domachuk
Deceased
Peter Domachuk
Demographics
33y, male
Date of death
2012-12-31
Finding date
2015-12-02
Cause of death
presumed fatal cardiac arrhythmia in the presence of coronary artery atherosclerotic disease and Addison's disease
AI-generated summary
Dr D., a 33-year-old physicist, was admitted to Hornsby Hospital on 27 December 2012 with abdominal pain, nausea, vomiting and joint pain. His presentation included hypotension (97/61), tachycardia (116/min), hyponatraemia (129 mmol/L), elevated lactate, and renal impairment—findings consistent with Addison's disease. A registrar ordered a cortisol test, but this was not documented in progress notes or handover. The patient was discharged after improvement over 48 hours. The cortisol result (critically low) was not validated until 2 January 2013, after the patient died of presumed fatal cardiac arrhythmia. Key lessons: inadequate communication and handover documentation of pending tests led to discharge before results were available; cortisol was not on the critical results notification list; separate validation systems delayed critical result reporting. Improved documentation, electronic task lists, critical results protocols and state-wide safety alerts are needed to prevent similar deaths.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- undiagnosed Addison's disease
- failure to document ordered cortisol test in progress notes
- failure to communicate pending cortisol test at discharge
- failure to document cortisol test in discharge summary
- delayed validation of cortisol result due to separate laboratory systems
- cortisol not on critical results notification list
- poor clinical handover documentation
- two separate screens for ordered vs completed tests in hospital system
- endocrinology laboratory closure over holiday period
Coroner's recommendations
- NSW Ministry of Health should publish a Patient Safety Watch to Local Health Districts to increase awareness of the potentially catastrophic outcome of undiagnosed adrenal insufficiency/Addison's disease
- NSW Ministry of Health should continue implementing a state-wide critical results notification policy and develop state-wide guidelines for notifiable thresholds for all critical results, including cortisol
- NSW Ministry of Health should establish a procedure whereby abnormal cortisol test results are sent to the Department of Forensic Medicine and to the State Coroner as a matter of course when the hospital becomes aware of the patient's death
Full text
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