Coronial
NSWhospital

Inquest into the death of Lorraine BARNES

Deceased

Lorraine Barnes

Demographics

85y, female

Coroner

Decision ofDeputy State Coroner, Magistrate Derek Lee,

Date of death

2016-05-01

Finding date

2019-12-13

Cause of death

sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury to the right lung, dementia, diverticulitis and a urinary tract infection were all significant conditions contributing to Mrs Barnes' death

AI-generated summary

Lorraine Barnes, an 85-year-old woman admitted to Wollongong Private Hospital for convalescence, died from sepsis with aspiration pneumonitis following iatrogenic lung injury. She developed severe malnutrition and electrolyte disturbances after refusing oral intake from hospital day 5 onwards. A fine-bore nasogastric tube was inserted on 30 April 2016 to provide enteral nutrition but was incorrectly positioned in the right lung due to a hiatus hernia and software error when reviewing chest x-rays (Dr N. and Dr C. reviewed the wrong x-ray image). Concentrated nutritional supplements were inadvertently delivered into the lung, causing perforations. Clinical lessons: (1) Early multidisciplinary case conferences should have been convened; (2) Dietician involvement should have been sought earlier when malnutrition was identified by 24 March; (3) The End-of-Life form lacked clarity distinguishing invasive versus non-invasive nutritional support; (4) Radiology review processes for weekend NGT x-rays needed improvement; (5) Adequate post-discharge services (Community Packages) should have been discussed prior to private hospital transfer.

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

Specialties

general medicinerespiratory medicinehaematologyrheumatologycolorectal surgeryintensive carepalliative caredieteticsradiology

Error types

diagnosticsystemdelaycommunication

Drugs involved

ciprofloxacinslow-kmagnesium aspartatepotassium chloridealbuminantibiotics

Clinical conditions

sepsisaspiration pneumonitismalnutritionelectrolyte disturbancehypokalaemiahypoalbuminaemiahypocalcaemiahypophosphataemiahypomagnesaemiadiverticulitisileusiatrogenic lung injurylung perforationurinary tract infectionAlzheimer's dementiagastro-oesophageal reflux diseasehiatus herniasjogren's diseasechronic obstructive pulmonary disease

Procedures

nasogastric tube insertionchest X-rayabdominal CT scanblood testholter monitor

Contributing factors

  • malnutrition and electrolyte disturbances from inadequate oral intake
  • refusal to eat from hospital day 5 onwards
  • misplacement of nasogastric tube in right lung instead of stomach
  • hiatus hernia complicating nasogastric tube insertion
  • software error in radiology imaging system (InteleViewer) resulting in review of incorrect x-ray image
  • lack of timely radiologist review of weekend x-ray
  • diverticulitis with secondary ileus
  • dementia affecting patient compliance and communication
  • absence of multidisciplinary case conferencing
  • delayed dietician referral
  • inadequate monitoring of nutritional intake and weight
  • inadequate discussion with family regarding nasogastric feeding implications

Coroner's recommendations

  1. The Hospital should review its Resuscitation/End Of Life, Appropriate Intervention Orders form, giving consideration to the need to clearly distinguish between invasive and non-invasive forms of nutritional support, and specify the type of nutritional support that is to be provided to a patient
  2. The Hospital should review its policy relating to the insertion of fine bore nasogastric tubes to ensure that they are able to be inserted on weekends and public holidays at the Hospital. Specific consideration should be given to whether, when a fine bore nasogastric tube is required for feeding on a weekend or public holiday, it should be able to be inserted on an acute ward. The review should take into account: (a) the new process for radiology review that ensures a radiologist looks at any x-ray relevant to correct placement of a nasogastric tube immediately when it is taken on a weekend or public holiday; and (b) the evidence of Professor Susan Kurrle given during the inquest as to the impact of delays in feeding older people and frail patients
Full text
Official source Archived copy

Related cases from NSW

NSW2024-12-03

Inquest into the death of Simon Cartwright

41y · Male·Septicaemia secondary to chronic peptic ulcer disease

Simon Cartwright, a 41-year-old man with schizophrenia and bipolar disorder, died in custody from septicemia secondary to chronic peptic ulcer disease. He had a documented ulcer history diagnosed in November 2020 and sho…

psychiatrygastroenterologydiagnosticsystempantoprazole
NSW2024-10-31

Inquest into the death of AB

34y · Male·Incision/stab wound to the neck

A 34-year-old male remandee died by self-inflicted neck wound while in custody at Metropolitan Remand and Reception Centre. He had been discharged from Risk Intervention Team management following a self-harm incident 7 d…

psychiatryemergency medicinediagnosticsystem
NSW2024-05-21

Inquest into the death of Mohamed Warwar

35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…

35-year-old Mohamed Warwar died in custody at Metropolitan Remand & Reception Centre from cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues an…

psychiatrycardiologycommunicationdiagnosticamisulpride

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.