Olive, Thomas (Tom) Andrew

Contributing factors

• Failure to recognise pattern of recurrent rhabdomyolysis episodes over 12 months
• Discharge letter from 30 June 2010 ED presentation not delivered to parents or GP
• Failure to review urine dipstick result (positive for blood and protein) in context with microscopy result (negative for red blood cells) suggesting myoglobin rather than haematuria
• Failure to perform CPK (creatine kinase) testing during acute episodes when rhabdomyolysis markers were present
• Failure to consider metabolic or genetic disease as differential diagnosis despite elevated liver enzymes and recurrent dark urine
• Inadequate communication of QAS clinical assessment to triage nurse on 25 August 2010
• Initial triage category 3 (30 minutes) rather than category 2 (10 minutes) on 25 August 2010, though delay of minutes did not alter outcome given severe hyperkalemia
• LPIN1 gene mutation extremely rare (first reported case in Australia), published in medical literature July 2010, after Tom's death

Coroner's recommendations

1. Policies should ensure discharge letters are reliably delivered to patients/carers and sent electronically to GPs
2. Hospitals should establish systems to review all pathology results including those from discharged patients, and document that significantly abnormal results have been reviewed with appropriate action taken
3. When dipstick urine analysis shows blood and protein positive but microscopy shows no red blood cells, clinicians should consider myoglobin (suggesting rhabdomyolysis) and consider CPK testing
4. Communication of pre-hospital assessment from QAS paramedics should be handed over to triage nurse and documented
5. QAS should continue development of electronic patient record system to consolidate multiple patient records and enable electronic transmission to receiving facilities
6. QAS eARF/CAD interface should allow automatic population of incident data and vital signs to reduce manual data entry burden
7. Hospitals should ensure paediatric emergency preparedness including staff training in emergency paediatric nursing and designation of paediatric emergency areas
8. Emphasis on sensible clinical practice: discharge letter distribution, result review, and follow-up communication should not require policy reminder but should be standard practice
9. Development of emergency management protocols for families with known LPIN1 gene mutations (such protocols now exist for Tom's family members)