Coroner's Finding: O'NEILL Louise Kay

Contributing factors

• propoxyphene overdose (fatal level detected)
• additional CNS depressant medications at toxic/supratherapeutic levels
• failure to obtain complete drug history from patient with known overdose history
• inadequate formal observation and vital sign monitoring while awaiting medical review
• undocumented vital signs taken informally by triage nurse
• extended waiting time (73 minutes) without formal observations recorded
• recurrent self-harm behaviour and prescription drug abuse
• emergency department overcrowding

Coroner's recommendations

1. The Minister for Health and the Department of Health continue the program of improvement to resources, both human and infrastructure, in Emergency Departments in hospitals in South Australia with a view to further reducing access block, in view of the recognised dangers of allowing patients to remain in triage areas without being seen by a doctor
2. Where a patient is permitted to lie on a barouche or bed in an Emergency Department while awaiting attention by a doctor, special care should be taken by nursing staff to monitor that patient's condition, particularly in relation to conscious state and rousability, in case the patient suffers an unexpected and undetected deterioration in condition