QLDhospital

Inquest into the death of Janis Ellen Doherty

Deceased

Janis Ellen Doherty

Demographics

57y, female

Coroner

Gallagher

Date of death

2020-05-16

Finding date

2025-10-08

Cause of death

Multi-organ failure due to drug-induced liver injury caused by sodium valproate hepatotoxicity

AI-generated summary

Mrs Doherty, a 57-year-old woman with CADASIL syndrome, was prescribed sodium valproate for migraine prophylaxis in November 2019. She developed acute hepatitis approximately 5 months later, presenting with jaundice, nausea, and dark urine. Critical failures in clinical management included: (1) failure to cease sodium valproate immediately upon admission to Caboolture Hospital despite recognition that it was a potential hepatotoxin and prescribed for non-essential migraine relief; (2) continuation of aspirin throughout her admission at Caboolture Hospital despite plans for liver biopsy, delaying the procedure; (3) inappropriate re-introduction of sodium valproate at Royal Brisbane and Women's Hospital on 29 April 2020 before DILI had been excluded on biopsy; and (4) failure to contact the prescribing neurologist for clarification about the drug's indication. Early cessation of sodium valproate at admission, cessation of aspirin when biopsy was contemplated, and avoidance of re-introduction might have offered her a reasonable chance of recovery, as at that point she had acute hepatitis without synthetic liver dysfunction.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

neurologyhepatologyinfectious diseasesgastroenterologygeneral medicineradiology

Error types

diagnosticmedicationcommunicationdelay

Drugs involved

sodium valproatesodium valproateaspirinamoxicillinatorvastatincoenzyme q10candesartan

Clinical conditions

drug-induced liver injurysodium valproate hepatotoxicityacute hepatitisacute liver injuryacute liver failuremulti-organ failureCADASIL syndromemigraine

Procedures

liver biopsy

Contributing factors

Failure to cease sodium valproate at hospital admission on 10 April 2020
Continuation of sodium valproate for 6 days after admission despite it being identified as a potential hepatotoxin
Failure to cease aspirin when liver biopsy was contemplated, delaying the procedure
Inappropriate re-introduction of sodium valproate on 29 April 2020 before drug-induced liver injury was excluded on biopsy
Failure to contact the prescribing neurologist (Dr W.) for clarification about the drug's indication
Late and indirect infectious diseases consultation
Reliance on CMV and Q fever as diagnostic possibilities when DILI was more likely

Coroner's recommendations

Metro North Hospital and Health Service undertake a review of the risk/benefits of undertaking percutaneous liver biopsy on patients taking aspirin with the view to establishing clear protocols and guidelines relating to: (a) when (if at all) it will be considered safe to proceed; (b) when (if at all) it will be considered unsafe to proceed; (c) when aspirin should be ceased in patients who may require or are planned to undergo percutaneous liver biopsy; and (d) the consultation process to be adopted, including which specialist disciplines are to be involved, and how those decisions are to be documented and recorded

Full text

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Source and disclaimer

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