Deceased
Simone Marie O'Donnell
Demographics
24y, female
Coroner
Decision ofMagistrate Baptie
Date of death
2016-10-12
Finding date
2021-02-08
Cause of death
Cardiac conducting system disease leading to asystole against a background of a structurally abnormal heart and a congenital cluster of disorders
AI-generated summary
A 24-year-old woman with complex congenital cardiac disease, cerebral palsy, and hydrocephalus was admitted to a secondary hospital with a respiratory tract infection and bradycardia with left bundle branch block. She deteriorated into asystole during overnight monitoring. Cardiac telemetry alarms sounded for approximately 25-30 minutes but nursing staff failed to respond appropriately. While the underlying cardiac conducting system disease was the direct cause of death, the delayed response to telemetry alarms represented a lost opportunity for resuscitation and potential temporary pacing intervention. Key failures included: inadequate supervision of junior medical staff regarding management planning; failure to chart prescribed antibiotics; alarm fatigue and demarcation culture among nursing staff; understaffing (two RNs and one EN for 30 beds); and equipment issues with telemetry batteries. Although experts agreed early intervention would have been difficult given rapid deterioration, prompt response was the standard of care expected.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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