Non-inquest findings into the death of RJH

Contributing factors

• Inappropriate administration of intravenous flecainide in setting of congestive cardiac failure
• Cognitive bias (outcome bias) from prior successful use of flecainide two years earlier
• Failure to consult cardiology despite complex cardiac history
• Lack of awareness of contraindication to flecainide in heart failure
• Limited pharmacy coverage over Christmas period with missed opportunity for independent review
• Lack of local protocol for intravenous flecainide administration
• Failure to review ECG changes between first and second infusions
• Prescriptions written for successive administration without reassessment
• Low potassium and elevated lactate not considered in context of flecainide administration
• Haemodynamic stability not recognised as reason to defer chemical cardioversion

Coroner's recommendations

1. Promotion of the large regional hospital's Dispensary Consult Service at the small regional hospital
2. Development and implementation of a guideline for intravenous flecainide (completed 13 February 2023)
3. The guideline makes clear intravenous flecainide should be used with caution noting contraindications, adverse effects, and drug interactions; recommends discussion with a cardiologist prior to administration and if a repeat dose is required; carries clear instruction to ensure administration only where cardiac monitoring and cardiorespiratory resuscitation equipment are available; sets out requirements for ECG monitoring and nursing observations
4. Presentation of this case at Morbidity & Mortality meeting at small regional hospital to discuss potential impact of missed communication between junior and senior medical officers
5. Medical officer orientation at small regional hospital to continue touching on clinical decision making and escalation for juniors