Krog, Shane Paul

Contributing factors

• Delayed medical review by on-call doctor (over 5 hours post-admission)
• Failure to recognize severity of persistent hypotension
• Failure to transfer to intensive care unit when clinically indicated
• Overly focused clinical judgment on rhabdomyolysis diagnosis
• Inadequate fluid resuscitation initially (1 litre over 10 hours)
• Inadequate response to abnormal pathology results showing high potassium and acute renal failure
• Dr L. attending continuing medical education lecture in late afternoon rather than remaining available
• Massive morphine ingestion (approximately 6 times average fatal dose)
• Severe pre-existing coronary artery disease
• Opiate naivety (no tolerance to morphine)
• Multi-organ failure present early in admission

Coroner's recommendations

1. Implementation of Patient Safety and Quality Improvement Service enabling district nurses to call on-call medical superintendents at larger centres for support and decision-making regarding transfers
2. Supply of i-STAT machines (advanced hand-held blood analysers) to rural hospitals to provide real-time lab quality results within minutes
3. Establishment of centrally managed clinical coordination units enabling district doctors to request patient transfers and obtain advice on management
4. Ongoing graded assertiveness training for nursing staff to enable appropriate clinical communication with doctors and escalation to management
5. Introduction of early warning identification systems in rural hospitals with automatic triggers for escalation to senior medical staff after specified time periods if doctors remain unavailable
6. Implementation of systems to ensure agency nurses are never left alone in rural hospitals, with experienced on-call nurses available by telephone or to attend at short notice
7. Endorse the changes and improvements implemented in rural hospital operations to improve patient safety and reduce preventable deaths