Inquest into the death of Brent Justin CROUGH

Contributing factors

• Envenomation from Eastern brown snake bite causing venom-induced consumption coagulopathy (VICC)
• Sudden collapse without prior clinical signs of envenomation
• Cardiac arrest occurring within first hour post-bite
• Absence of pressure immobilising bandage prior to collapse
• Delayed recognition of severity before collapse
• Guidelines inadequately address preventive treatment for envenomed patients without obvious clinical symptoms
• Reliance on blood test results with 35-60 minute turnaround time
• Lack of bedside testing for venom detection

Coroner's recommendations

1. Urgent review of Snakebite and Spiderbite Clinical Management Guidelines 2013 to address the identified gap in management of envenomed brown snake bite patients without obvious clinical symptoms prior to collapse
2. Establish Expert Review Panel to review Guidelines including divergent expert views
3. Provide Expert Review Panel with coroner's findings and request examination of changes needed
4. Consider adding discretion for treating doctors to administer antivenom in advance of blood test results following risk assessment in conjunction with on-call toxicologist
5. Adopt patient-centred care approach with explicit discussion of symptoms of envenomation, risk of sudden collapse, risks and benefits of early antivenom administration, and shared decision-making
6. Add separate appendix to Guidelines specifically for brown snake bite emphasising nil or minimal signs prior to sudden collapse
7. Add patient information sheet for suspected brown snake bite describing process and emphasising risk of sudden collapse with minimal warning
8. Amend Snakebite Clinical Pathway to prioritise early contact with on-call toxicologist as expert resource
9. Include detailed history and examination elements in risk assessment (snake visibility, proximity, visible puncture wound, first aid applied, any symptoms)
10. Add plain English explanations for medical terms in charts
11. Add warning on Snakebite Observation Chart regarding immediate reporting of any signs of envenomation to treating doctor
12. Ensure adequate funding for expert on-call toxicologist availability through Poisons Information Hotline with quick access number for treating doctors
13. Regularly review Guidelines to incorporate ongoing research, advances, and availability of bedside testing methods
14. Notify NSW State Coroner and Head of NSW Department of Forensic Medicine that full autopsy of suspected brown snake bite victims is recommended to advance understanding of envenomation
15. Formalise arrangements for providing antemortem blood specimens of brown snakebite fatalities to research hospital for research purposes
16. Instruct pathology lab technicians that 'clotted coags' result may indicate brown snake envenomation and should be reported urgently to treating doctor
17. HNELHD to conduct public education campaign regarding dangers of Eastern Brown Snake and appropriate response to suspected bite
18. HNELHD to provide regular training for ED staff and practitioners on Guidelines, Australian Therapeutic Guidelines, risk of sudden collapse, and availability of toxicologist expert advice, using Brent's case as case study
19. HNELHD to ensure staff familiarity with Snake Observation Chart and proper contemporaneous documentation procedures

Further listening

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