Coronial
SAhospital

Coroner's Finding: EVANS Shaun Michael

Deceased

Shaun Michael Evans

Demographics

22y, male

Date of death

2001-10-01

Finding date

2006-01-12

Cause of death

Mixed Diflunisal and Buproprion (Zyban) toxicity

AI-generated summary

A 22-year-old man presented to Royal Adelaide Hospital's Emergency Department after taking approximately 110 Zyban (bupropion) tablets as a suicide attempt. Unknown to treating staff, he had also ingested a potentially lethal quantity of diflunisal (an anti-inflammatory). He died from mixed bupropion and diflunisal toxicity. Key clinical failures included: failure to use activated charcoal (rejected based on flawed second-hand advice from poison centre rather than direct consultation), delayed medical review (45 minutes), delayed decontamination by 1.5 hours, delayed intubation despite seizures and declining consciousness, and failure to recognise the multi-drug overdose despite positive paracetamol and salicylate blood tests. The patient's non-disclosure of diflunisal was a complicating factor, but inadequate questioning by staff contributed. While the combined toxicity was likely fatal regardless, optimal supportive care with early intubation and consideration of charcoal decontamination with airway protection were not provided.

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

Specialties

emergency medicinetoxicologyintensive care

Error types

diagnosticcommunicationdelaysystem

Drugs involved

bupropiondiflunisalalcoholparacetamolsalicylatediazepam

Clinical conditions

acute bupropion toxicityacute diflunisal toxicityseizurestachycardiacardiac conduction abnormalitiesaltered consciousnessaspiration riskacute poisoning

Procedures

nasogastric tube insertionwhole bowel irrigationintubationelectrocardiogramblood testingtoxicology analysis

Contributing factors

  • Non-disclosure of diflunisal ingestion by patient
  • Failure to take complete drug history from patient
  • Reliance on second-hand information from poison centre rather than direct consultation
  • Flawed advice from poison centre based on misunderstanding that charcoal had already been given
  • Delayed triage category (Category 3 instead of Category 2)
  • Delayed medical review (45 minutes)
  • Delayed availability of decontamination agent (whole bowel irrigation not obtained from ward for extended period)
  • Four failed nasogastric tube insertion attempts before successful placement
  • Delayed intubation despite deteriorating consciousness and recurrent seizures
  • Failure to recognise multi-drug overdose despite positive paracetamol and salicylate blood tests
  • Insufficient consideration of supportive care measures relative to decontamination

Coroner's recommendations

  1. Consider restricting prescription quantities of Zyban to prevent large quantities being available to patients at risk
  2. Clarify for clinical staff the appropriateness of administering activated charcoal for slow-release drug overdoses including bupropion, particularly regarding timing and safety with airway management
  3. Encourage doctors in emergency settings to personally utilise Poison Information Centre services rather than delegating to nursing staff
  4. Discourage the practice of doctors delegating communication with Poison Information Centres to nursing staff
  5. Instruct clinical staff responsible for triage to accord to drug overdose presentations triage category 1 or 2 to minimise delay
  6. Ensure that appropriate decontaminants are always made immediately available within emergency departments
  7. Ensure thorough enquiry of all presenting patients regarding the number, quantity and identity of all substances ingested, and ensure adequate documentation of such enquiries and responses
  8. Ensure thorough consideration of the possibility of multiple drug overdose, including timely administration and evaluation of blood tests and closer attention to acid-base status
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