Coronial
NTcommunity

Inquest into the death of Marilyn Lalara

Deceased

Marilyn Dumaberangergamia Lalara

Demographics

48y, female

Date of death

2010-04-04

Finding date

2011-07-27

Cause of death

acute myocarditis resulting from systemic viral infection

AI-generated summary

A 48-year-old Aboriginal woman with chronic diseases (diabetes, COPD, ischaemic heart disease) presented with ongoing chest infection symptoms across multiple clinic visits between 30 March and 4 April 2010. Despite five presentations to clinic staff, there was no escalation to medical officer consultation, which might have identified myocarditis earlier. On 4 April, she presented severely unwell with dramatically falling haemoglobin and high blood sugar. Although rapidly evacuated to Alyangula clinic where she was assessed as critically ill and awaiting air evacuation to hospital ICU, no aircraft were available due to maintenance, pilot illness, and another category-1 patient. She arrested during waiting and died. The coroner found inadequate escalation protocols at remote clinics, gaps in staff training for point-of-care testing, and insufficient air-medical fleet capacity contributed to her death, though myocarditis is intrinsically difficult to diagnose ante-mortem.

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

Specialties

emergency medicinecardiologyintensive carepathologyretrieval medicine

Error types

diagnosticdelaysystem

Drugs involved

antibioticsaspirindiabetes medicationsantihypertensive medicationsasthma and copd medications

Clinical conditions

acute myocarditissystemic viral infectionchest infectiondiabetes type 2chronic obstructive pulmonary diseaseischaemic heart diseaserenal failure stage 1cardiac arrestanaemiapresumed haemolysishyperglycaemia

Procedures

blood transfusion (arranged but not administered)nebuliser therapyelectrocardiogram

Contributing factors

  • failure to escalate care to medical officer after multiple clinic attendances
  • delayed diagnosis of myocarditis
  • no ECG performed on 2 April 2010 despite chest pain
  • lack of i-STAT testing capability at Alyangula clinic
  • absence of air-medical aircraft available for evacuation
  • aircraft offline for maintenance
  • pilot illness with no backup pilot available
  • another patient tasked as higher priority category 1
  • pre-existing chronic diseases (diabetes, COPD, ischaemic heart disease, renal disease) reducing survival prospects
  • unexplained rapid decline in haemoglobin levels

Coroner's recommendations

  1. Department of Health – Remote Health should consider a protocol requiring consultation with a doctor on at least the third presentation unless there is clear diagnosis and clinical improvement, with amendment to the Health Atlas to reflect this
  2. Remote Health should reinforce to all staff the need for accurate checking of i-STAT cartridge dates and adherence to monitoring systems
  3. As part of medical practitioner induction, certification for use of the i-STAT machine should be mandatory
  4. Government and Department of Health should work hard at ensuring the new aeromedical service (CareFlight Top End Medical Service) is implemented as quickly as possible rather than the extended implementation period planned for January 2012 to January 2013
Full text
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Source and disclaimer

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