Coronial
NSWhospital

Inquest into the death of Dr Peter Domachuk

Deceased

Peter Domachuk

Demographics

33y, male

Coroner

Decision ofDeputy State Coroner Forbes

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 Peter Domachuk, 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. Report an inaccuracy.

Specialties

emergency medicinegeneral medicineendocrinologycardiologypathology

Error types

communicationsystemdelay

Drugs involved

diclofenacmetformin

Clinical conditions

Addison's diseaseadrenal insufficiencycoronary artery atherosclerotic diseasecardiac arrhythmiaacute kidney injuryhyponatraemiahypotensiontachycardiatype 2 diabetes

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

  1. 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
  2. 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
  3. 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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