Maggable, Kenneth
Deceased
Kenneth Maggable
Demographics
70y, male
Date of death
2005-08-09
Finding date
2008
Cause of death
Acute coronary occlusion due to extensive coronary atherosclerosis
AI-generated summary
Kenneth Maggable, a 70-year-old man with chronic obstructive pulmonary disease, asthma, and prostate cancer, presented twice to Cairns Base Hospital on 8 August 2005 with respiratory complaints. After discharge at 4:50 AM on 9 August, he collapsed at home and died at 6:25 AM. Autopsy showed acute coronary occlusion due to coronary atherosclerosis. Clinical concerns included: a first-year intern (Dr T.) apparently making discharge decisions without documented senior review; inadequate oxygen saturation monitoring documentation (91% room air at admission not clearly improved at discharge); and poor record-keeping practices. However, the coronary occlusion was complete and fatal regardless of oxygen therapy. Key deficiencies identified were inadequate supervision of junior staff, lack of documented senior consultation, and absence of electronic medical records preventing proper clinical assessment and follow-up communication with the GP.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- chronic obstructive pulmonary disease
- emphysema
- prostate cancer
- heavy smoking history
- inadequate documentation of oxygen saturation rates
- apparent lack of senior medical review of discharge decision
- poor record-keeping practices
- staff shortages in emergency department
- discharge in early morning hours to unwell patient
Coroner's recommendations
- The Regional Health Authority in conjunction with Queensland Health review or develop and implement procedures for auditing interns in their clinical record keeping practices and procedures
- Queensland Health undertake a feasibility study into the implementation of an integrated electronic/computerised patient information system, incorporating clinical notes, treatment plans and discharge summaries, allowing for access to patient data across the Cairns Health Service District at least
- Documentation that consultation with a Registrar or other consultant has occurred, including the time of such consultation, should be included in the clinical record
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