Coroner's Finding: MILLER Allan Kenneth
Deceased
Allan Kenneth Miller
Demographics
56y, male
Date of death
2007-11-17
Finding date
2012-03-07
Cause of death
disseminated nocardiosis involving central nervous system, kidneys, liver and thyroid with bilateral lower lobe pneumonia
AI-generated summary
Allan Kenneth Miller, 56, died from disseminated nocardiosis (rare bacterial infection) that was not diagnosed during his 12-day RAH admission. Clinicians initially suspected metastatic lung cancer based on presentation and imaging, which was objectively reasonable. Two CT-guided biopsies on 8-9 November were attempted but unsuccessful due to patient intolerance; further biopsy under sedation/anaesthesia was planned for Monday 12 November. Over the weekend, Mr Miller's cognitive function deteriorated, precluding his consent. His wife did not consent to further invasive procedures. The coroner found the clinical team acted appropriately and the wife's decision was reasonable, but noted a possible preventable element: if anaesthetic services had been immediately available on Friday 9 November for a sedated/anaesthetised biopsy while the patient could still consent, nocardiosis might have been diagnosed and treated before dissemination to the brain, potentially altering outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to obtain successful tissue diagnosis via biopsy
- patient intolerance of CT-guided biopsy procedures without sedation/anaesthesia
- patient cognitive deterioration over weekend preventing further consent
- family decision against further invasive procedures
- unavailability of immediate anaesthetic services on Friday afternoon to facilitate sedated biopsy
- rarity and diagnostic difficulty of nocardiosis
- radiological findings consistent with metastatic lung cancer masking true diagnosis
Coroner's recommendations
- These findings be drawn to the attention of the General Manager of the Royal Adelaide Hospital with a view to examining the issue as to whether, if a repetition of the circumstances in this case should occur, immediate anaesthetic services could be provided to a patient such as Mr Miller
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