Inquest into the death of Dion Daniels

Contributing factors

• Failure to contact District Medical Officer or available doctor
• Failure to obtain blood pressure reading
• Failure to conduct ECG despite saying to nurse it would be done
• Failure to consider cardiac diagnosis despite risk factors and clinical presentation
• Failure to consult patient's medical history showing persistent hypertension, prior chest pain, obesity, smoking
• Delay in inserting intravenous cannula (45 minutes) despite provisional diagnosis of severe dehydration
• Failure to escalate for 13 minutes after cardiac arrest at 8.15pm
• Failure to conduct Troponin testing
• Inadequate prior cardiac risk assessment and management in preceding 3 years at clinic
• CARPA manual (5th edition) lacked specific guidance on heart attacks without chest pain
• CARPA manual dehydration section buried in child health chapter rather than emergency or adult sections
• Smoking (3 cigarettes) immediately before football in extreme heat possibly precipitated plaque rupture

Coroner's recommendations

1. CARPA manual should be amended to include specific sub-chapter in Emergency section addressing diagnosis of heart attacks without chest pain, and how cardiac disease diagnosis may be confused with dehydration
2. CARPA manual should be amended to include separate chapter on dehydration specifically addressing adults
3. CARPA manual Emergency section should specify that ECG test should be conducted when blood pressure cannot be obtained or hypotension exists, and that nurses must phone DMO for medical assistance in such circumstances
4. Substantial education should be provided to medical personnel and Aboriginal people in remote NT areas regarding early onset of cardiac disease in young Aboriginal people and that heart attacks can occur without chest pain
5. Department of Health should implement coordinated strategy for screening and proactive testing for cardiac disease in young Aboriginal people in remote areas, extending to NGO sector including Sunrise Health
6. Department of Health should coordinate strategy to educate medical practitioners and nurses in proactive testing and screening for cardiac disease
7. Sunrise Health Service should conduct review of practices and staff training with emphasis on proactive cardiac disease screening, appropriate testing and treatment per CARPA protocol, and liaison with Department of Health
8. Sunrise Health Service should advertise that untreated heart disease kills young people and emphasise that coronary heart disease can strike without warning and without chest pain; importance of regular wellness checks must be emphasised
9. Public health campaign targeted at Aboriginal people should emphasise dangers of smoking and high smoking rates in NT Aboriginal communities, including that smoking before physical exertion in heat can cause arterial spasm and heart attack
10. ISTAT devices should be installed in all medical clinics in NT given their effectiveness; if not available, all clinics must ensure functioning Troponin test kit is available
11. Most up to date ECG devices capable of digital transmission to on-call cardiologist should be installed in all NT medical facilities
12. Nurse education should emphasise not making provisional diagnosis without clear CARPA manual support, and consulting medical practitioner immediately if in doubt; must review patient history and document findings in notes
13. CARPA manual editors should consider findings of this inquest when preparing next edition