Inquest into the death of Lynette Maree YOUNG
Deceased
Lynette Maree Young
Demographics
46y, female
Date of death
2012-04-29
Finding date
2015-07-27
Cause of death
Shock following interferon alpha treatment following removal of a melanoma
AI-generated summary
Lynette Young, 46, died of shock secondary to pericarditis with cardiac tamponade following interferon alpha treatment for melanoma. She presented with chest pain to Dubbo Base Hospital where multiple clinical failures occurred. Key failures included: inadequate vital sign observations despite Between the Flags policy requiring hourly monitoring in a Category 2 patient; failure to document observations and maintain fluid balance charts in a patient on IV therapy; inadequate handover between shifts; absence of the primary nurse from HDU without proper handover of care; failure to recognise deteriorating signs (undetectable blood pressure, tachycardia, hypothermia) and delayed MET call activation. A locum consultant (Dr R.) did not read progress notes routinely, did not recognise or act on vital sign abnormalities, and issued contradictory orders regarding fluid therapy. Early echocardiography might have identified cardiac tamponade requiring urgent intervention. Systemic improvements have since been implemented.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Pericarditis with exudate causing cardiac tamponade secondary to interferon alpha therapy
- Inadequate vital sign observations contrary to Between the Flags policy
- Failure to maintain fluid balance chart
- Poor documentation and record-keeping
- Inadequate handover between nursing shifts
- Absence of primary nurse (Nurse Kaufusi) from HDU without handover of care
- Failure to recognise deteriorating condition (undetectable blood pressure, tachycardia, hypothermia)
- Delayed MET call activation
- Locum consultant did not read progress notes
- Locum consultant did not recognise significance of vital sign abnormalities
- Lack of echocardiography technician available on weekend
- No documented telemetry monitoring despite patient being connected to telemetry unit
Coroner's recommendations
- That Dubbo Base Hospital consider compiling and circulating within the hospital a list of personnel who have sufficient training, qualifications or experience to be able to perform urgent after hours bedside ultrasound or echocardiograms
- That Dubbo Base Hospital give consideration to encouraging medical staff to take up training in bedside ultrasound
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