Coronial
SAhospital

Coroner's Finding: FENSOM Angela Catherine and TAANKINK Johaanes Andrew

Deceased

Angela Catherine Fensom and Andrew Johaanes Taankink

Demographics

unknown

Date of death

2009-08-18 and 2009-10-01

Finding date

2013-02-08

Cause of death

Ms Fensom: influenza A (H1N1 2009, pandemic swine flu) with myocarditis causing cardiac failure. Mr Taankink: hypoxic respiratory failure, H1N1 pneumonitis, acute respiratory distress syndrome

AI-generated summary

Two deaths from H1N1 influenza in 2009. Ms Fensom (41) died from myocarditis complicating swine flu after inadequate recognition and management of persistent hypotension at Millicent Hospital. Her condition required escalation to inotropic support and tertiary ICU care from at least mid-morning on 18 August, but the treating registrar (Dr V.) failed to recognise the seriousness of persistently low blood pressure despite it not responding to fluid therapy. Mr Taankink (26), an asthmatic, was prescribed Tamiflu on 6 August but did not fill it; if filled within 48 hours, pneumonia development might have been prevented. After admission on 10 August with pneumonia, he required intubation and mechanical ventilation by 11 August evening (24 hours earlier than it occurred), with prompt retrieval to tertiary ICU. Confusion about clinical responsibility between two physicians and reluctance to escalate care after hours contributed to delayed intervention.

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

Specialties

emergency medicinegeneral practiceintensive careinfectious diseasesrespiratory medicine

Error types

diagnosticcommunicationsystemdelay

Drugs involved

oseltamivirparacetamolsalbutamolflixotideadrenalineantibioticsprednisolone

Clinical conditions

influenza a h1n1 2009 (swine flu)myocarditispneumoniaacute respiratory distress syndromerespiratory failurehypoxemiasevere hypotension/shockasthmaviral gastroenteritis (misdiagnosis)

Procedures

intubationmechanical ventilationCPAParterial blood gas monitoringcardiac monitoringelectrocardiogramnasal prongs oxygen deliverynon-rebreather mask oxygen deliveryintravenous fluid administrationinotropic support (adrenaline)intubation by retrieval team

Contributing factors

  • failure to recognise severity of persistent hypotension in Ms Fensom
  • inadequate vital sign monitoring frequency
  • failure to escalate care to senior clinician or ICU
  • reliance on consciousness as marker of wellbeing rather than objective vital signs
  • failure to prescribe Tamiflu to Mr Taankink after admission
  • delayed intubation and mechanical ventilation in Mr Taankink
  • delayed retrieval to tertiary ICU facility
  • unclear clinical responsibility between two physicians at Mount Gambier Hospital
  • reluctance to contact senior physicians after hours
  • inadequate handover and communication between general practitioner and hospital

Coroner's recommendations

  1. Findings be drawn to attention of Minister for Health and Chief Executive Officers of all public hospitals in metropolitan and country South Australia
  2. Findings be drawn to attention of Chief Executive Officer of Australian Medical Association, South Australia branch, for education of members
  3. Minister for Health cause systems and protocols to be designed to ensure country hospitals in South Australia are staffed with appropriate medical expertise and patients are properly and regularly reviewed by medical practitioner of appropriate and relevant experience
  4. Minister for Health ensure promulgation within public hospitals in both metropolitan and country South Australia of systems and protocols designed to enable medical practitioners and nurses to recognise and appropriately respond to deteriorating patients
  5. Implementation of criteria-driven protocols that automatically trigger senior clinician review when vital signs fall below pre-identified thresholds
  6. Universal implementation of duty doctor system in country practices ensuring 24-hour medical practitioner availability and regular senior medical review
  7. Implementation of nationally recognised clinically deteriorating patient observation chart with colour coding and standard escalation guidelines
Full text
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