Inquest into the death of June Nutter
Deceased
June Nutter
Demographics
58y, female
Date of death
2015-12-20
Finding date
2018-12-04
Cause of death
lymphangitic carcinomatosis leading to hypoxaemic respiratory failure and cardiac arrest
AI-generated summary
June Nutter, a 58-year-old woman presenting with weight loss, anorexia, and unexplained shortness of breath, underwent gastroscopy and colonoscopy at a private hospital to investigate suspected gastric pathology. She had hypoxaemia (oxygen saturations 90% on room air) preoperatively. Though the procedure was reasonable, she was admitted to HDU where care had deficiencies: incomplete vital sign documentation overnight, nursing staff left her unattended on 20 December 2015, and during resuscitation following cardiac arrest, adrenaline was not administered per guidelines and airway management issues occurred. She died of lymphangitic carcinomatosis, a rare gastric cancer undiagnosed ante-mortem. Experts agreed the resuscitation deficiencies did not affect outcome; she died from natural disease progression. The coroner found early hospital transfer was not definitively required, though better monitoring and adherence to ALS protocols would represent optimal practice.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- poorly differentiated gastric adenocarcinoma with lymphatic invasion (lymphangitic carcinomatosis)
- failure to diagnose advanced gastric cancer ante-mortem
- hypoxaemia not explained by initial investigations
- failure to administer adrenaline during cardiac arrest resuscitation
- suboptimal airway management and ventilation during resuscitation
- lack of comprehensive vital sign documentation overnight
- nursing staff left patient unattended in bathroom
Coroner's recommendations
- Implementation of robust procedures to ensure Career Medical Officers are informed of all relevant clinical and operational policies prior to commencing first shift
- Installation of appropriate signs and directions at access points and elevator exit points used by Ambulance Service NSW personnel to allow independent determination of patient location
- Investigation of feasibility of simulation-based training in airway management and ventilation for nursing staff, and incorporation into BLS and ALS training as part of ongoing competency assessment
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