Inquest into the death of Addison Anthony

Contributing factors

• Underlying autoimmune disease not diagnosed until late presentation
• Failure of locum doctor to access shared electronic health record showing positive ENA results
• Lack of continuity of care between Katherine Hospital and Correctional Health services
• Carbuncle from unclear origin possibly related to autoimmune disease
• Patient reluctance to engage with western medical concepts
• Lack of family presence during hospitalisation
• Lack of interpreter services
• Delay in medical team coordination of complex multi-system illness

Coroner's recommendations

1. The Commissioner of Correctional Services ensure that appropriate processes and procedures are in place to advise the families of prisoners whenever a prisoner is under medical care and at significant risk of dying
2. The Department of Health ensure that the processes and procedures for accessing the Shared Electronic Health Record are appropriate and that the records are being accessed in appropriate cases
3. The Top End Health Service develop a system wide training program on the requirements of patient monitoring, track and trigger charts and methodologies in escalating care
4. The Top End Health Service take all reasonable steps to ensure access to interpreters for indigenous patients where there is a need due to language or cultural barriers