KS - Non-inquest findings

Contributing factors

• Misdiagnosis of NSTEMI at rural hospital when primary diagnosis was sepsis
• Elevated troponin interpreted as cardiac biomarker without full clinical context
• Failure to recognize sepsis as a cause of troponin elevation
• Administration of multiple anticoagulants (aspirin, clopidogrel, enoxaparin) in addition to ongoing rivaroxaban in context of sepsis
• Limited clinician knowledge of new oral anticoagulants (rivaroxaban)
• Delayed availability of blood culture results (weekend pathology services)
• Delayed initiation of appropriate antibiotic therapy (flucloxacillin)
• Ischaemic stroke from sepsis-induced thrombosis converting to haemorrhagic stroke, exacerbated by anticoagulation
• Treating team did not discuss death with coroner before issuing cause of death certificate

Coroner's recommendations

1. Department of Health Patient Safety Unit to develop and issue a State-wide Patient Safety Alert regarding recognition of sepsis in patients with elevated troponin in the context of fever, lethargy, known history of long-term infection and antibiotic use, and/or in absence of other ischaemic cardiac symptoms
2. Development of a Workplace Instruction for the RHHS outlining that patients on existing anticoagulants who present with increased troponin in the absence of other ischaemic cardiac symptoms should not be prescribed additional anticoagulant therapy without consultation with a cardiologist, emergency consultant, and/or intensive care physician
3. Identification of new oral anticoagulants in a specific area on the National Inpatient Medication Chart (similar to Warfarin area) to facilitate easier identification by all staff
4. Referral to Department of Health Medicines Regulation Unit regarding National Inpatient Medication Chart Committee to address identification of new oral anticoagulants
5. Establishment of a working group to review current weekend pathology arrangements and consider increased patient acuity and planned service expansion
6. Investigation of automated notification systems for clinical test result availability to clinicians
7. Development of clinical protocol for management of acute coronary syndrome in rural settings based on National Heart Foundation of Australia and Cardiac Society of Australia Guidelines
8. Review of current NSTEMI protocol to include discussion of newer anticoagulants and clarification of troponin testing and interpretation in light of 2011 Addendum recommendations
9. Implementation of comprehensive Emergency Department Cardiac Chest Pain Risk Stratification Pathway and Medical Assessment Tool for non-tertiary hospitals