Tanner, Marjorie Joyce
Deceased
Marjorie Joyce Tanner
Demographics
female
Date of death
2005-01-21
Finding date
2007-11-28
Cause of death
Coronary atherosclerosis with ischaemic small bowel and Alzheimer's disease
AI-generated summary
Marjorie Joyce Tanner, an elderly woman with Alzheimer's disease, presented to Maryborough Hospital with a three-day history of abdominal pain, distension, and vomiting. Initially diagnosed with simple constipation and treated with enema and laxatives, she was discharged then readmitted when symptoms persisted. At Hervey Bay Hospital, bowel obstruction was confirmed. Due to elevated lactate on arterial blood gas and lack of available ventilated ICU bed at Hervey Bay, she was deemed too high-risk for local surgery and transferred by helicopter to Nambour General Hospital. During flight, she vomited, aspirated, and deteriorated. She died from a combination of coronary atherosclerosis and ischaemic bowel. The coroner found clinical decisions reasonable but identified systemic issues: inadequate initial investigation (no urgent CT scan arranged), insufficient medical staffing at Maryborough, limited ICU capacity at Hervey Bay, and use of undersized aircraft for transfer. Key lessons: earlier aggressive investigation for persistent obstruction symptoms, adequate ICU capacity planning for regional hospitals, and appropriate aeromedical retrieval resources.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Initial misdiagnosis of simple constipation rather than mechanical bowel obstruction
- Delayed definitive imaging - barium enema not arranged urgently on first presentation
- Inadequate medical staffing at Maryborough Hospital - single resident medical officer on duty in evening
- Insufficient ICU ventilated bed capacity at Hervey Bay Hospital
- Use of undersized helicopter for inter-hospital transfer of unstable patient
- Patient agitation and removal of nasogastric tube during flight
- Aspiration of vomitus during helicopter flight due to aircraft constraints preventing proper airway management
- Delayed helicopter dispatch due to paging system malfunction
- Significant lactate elevation on arterial blood gas indicating tissue hypoxia
Coroner's recommendations
- Appropriate procedures and protocols should be put in place conjointly by Queensland Ambulance Service, QEMS, and Queensland Health to ensure that appropriately sized patient retrieval aircraft are utilised to meet foreseeable medical contingencies during inter-hospital transfer flights
- Endorsement of staffing increases and service improvements implemented by Fraser Coast Health Service District including increased surgical establishment, principal house officer numbers, and anaesthetic staffing
- Consideration of establishing one hospital with appropriate levels of medical and nursing staff to meet flexibility of population demands, as recommended by the review committee
- Implementation of procedures to ensure urgent imaging (CT scan or barium enema) can be arranged within reasonable timeframes for acute bowel obstruction cases
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