Inquest into the death of David Freeman

Contributing factors

• Administration of aspirin to patient with known ibuprofen hypersensitivity
• Lack of accessible electronic medical records
• Absence of on-site medical officer
• Nursing staff without emergency care accreditation or advanced life support training
• Failure to administer adrenaline despite availability and clinical indication
• Poorly coordinated escalation pathways during business continuity plan
• Inadequate staff orientation to new emergency department
• Inadequate assessment of nursing staff competency prior to engagement
• Unclear triaging and referral protocols
• Unstable asthma with recent corticosteroid use
• Concurrent use of methylamphetamine and alcohol

Coroner's recommendations

1. Ernestina Amarh-Ashitei be referred to Health Care Complaints Commission/NMBA for investigation regarding unsatisfactory professional conduct in record keeping, administration of aspirin without informing prescriber of ibuprofen allergy, and competency of nursing skills
2. HNELHD rewrite and simplify Tenterfield Hospital Business Continuity Plan to provide singular set of clear, succinct instructions on single page with unambiguous escalation pathways for nursing staff when no medical officer on site
3. HNELHD review existing referral pathways and ensure clear pathways for referral to respiratory and other specialists for patients with repeated severe asthma exacerbations on multiple courses of prednisolone
4. Copy of findings sent to NSW Health recommending amendment of Chest Pain Pathway to include cautions: 'Does the patient have severe asthma?' and 'Does the patient have an aspirin/NSAID sensitivity?'
5. Copy of findings sent to NSW Minister for Regional Health and NSW Health regarding systemic issues of resourcing