PATELESIO, Etevise
Deceased
Etevise Debroh Taai Patelesio
Demographics
29y, female
Date of death
2023-05-24
Finding date
2024-07-30
Cause of death
Hypoxic-ischaemic encephalopathy due to cardiac arrest of undetermined cause
AI-generated summary
A 29-year-old woman with multiple comorbidities (Turner syndrome, type 1 diabetes, end-stage renal disease) presented to the ED in acute behavioural disturbance, requiring physical and chemical restraint. She received 5mg droperidol IM for sedation, which was appropriate given her frailty. However, formal vital sign monitoring post-sedation was not undertaken between 07:50-08:00 hours, contrary to work instructions requiring monitoring every 5 minutes for 20 minutes. She was found unresponsive with hypoxia at 08:00 hours, suffered cardiac arrest of undetermined cause, and died from hypoxic-ischaemic encephalopathy. While the arrest cause remains unclear, earlier detection via continuous monitoring may have enabled earlier intervention. Key clinical lessons: ensure post-sedation monitoring compliance in high-risk patients; implement continuous monitoring including pulse oximetry, ECG, and end-tidal CO2; clarify conflicting guidelines on monitoring frequency.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Failure to undertake formal vital sign monitoring post-sedation despite work instructions requiring monitoring every 5 minutes for 20 minutes
- No continuous electronic monitoring attached despite presence of monitor equipment
- Absence of oxygen saturation monitoring due to hand bandaging for self-harm prevention
- Confusion in work instructions regarding monitoring frequency (5 minutes vs 15 minutes)
- Acute behavioural disturbance in patient with significant medical comorbidities
- Respiratory depression and hypotension from droperidol in context of end-stage renal disease
- Unwitnessed cardiac arrest - approximately 10 minutes without monitoring
Coroner's recommendations
- Urgent clarification and amendment of WMHHS Work Instruction on Emergency Department Sedation for Management of Acute Behavioural Disturbance to eliminate confusion between Algorithms regarding monitoring frequency (5 minutes vs 15 minutes)
- Queensland Health guideline for Management of Acute Severe Behavioural Disturbance in Emergency Departments to be urgently amended to clearly recommend: continuous pulse oximetry, vital signs every 5 minutes for 20 minutes, and SAT score every 15 minutes
- Implementation of continuous monitoring for all sedated patients following acute severe behavioural disturbance, including continuous pulse oximetry, continuous ECG monitoring, and continuous end-tidal carbon dioxide (ETCO2) monitoring
- Appropriate alarm parameters should be set and activated on all continuous monitoring equipment to alert to critical deterioration
- ETCO2 monitoring via nasal prongs should be extended beyond resuscitation areas to identify hypoventilation or apnoea early in spontaneously breathing patients following sedation
- Finalization and implementation of documented procedures for physical and mechanical restraint (completed by WMHHS as Restrictive Practices procedure)
- Implementation of structured escalation responses to acute behavioural disturbance (such as Code Grey or Behaviour of Concern protocols) with senior clinician involvement
- Staff education regarding updated work instructions and monitoring requirements
- Consideration of broader system factors including ED overcrowding and staffing adequacy to enable focus on individual patient care
Full text
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