Coroner's Finding: VASSALLO Virginia

Contributing factors

• failure to diagnose staphylococcus aureus endocarditis on initial presentation
• failure to consider bacterial infection despite fever, severe systemic symptoms, and critically low platelet count
• failure to admit patient with unknown severe illness and profound thrombocytopenia
• incomplete blood examination film review not available to treating clinician on day of presentation
• failure to obtain blood cultures on initial presentation
• lack of availability of previous medical records and ambulance report to treating physicians
• delayed access to haematology consultation on 20 October
• severe overcrowding and bed-block in Emergency Department
• staff stress and overwork contributing to diagnostic error
• misinterpretation of low platelet count as idiopathic thrombocytopenic purpura rather than marker of severe infection

Coroner's recommendations

1. Alert the medical profession through professional bodies to consider infective endocarditis in patients with known valvular disease presenting with symptoms of infection
2. Implement echocardiography earlier in the diagnostic pathway when endocarditis is suspected
3. Establish a system at the Hospital to ensure previous medical files are made available to Emergency Department treating practitioners
4. Ensure South Australian Ambulance reports are made available to Emergency Department treating practitioners
5. Medical profession should consider more efficient assessment and communication of complete blood examination film review results when they indicate significant pathology such as septicaemia, particularly to discharged patients
6. Continue monitoring and development of strategies to address Emergency Department overcrowding, bed-block, ambulance diversion, and staff workload to reduce risk of professional error
7. Address nursing staff shortages and implement recruitment and retention programs to support adequate bed availability