Deceased
Eileen Hazel Cook
Demographics
76y, female
Date of death
2010-01-21
Finding date
2014-02-05
Cause of death
hospital acquired pneumonia, multiple organ dysfunction and small bowel obstruction with contributing smoking related lung disease
AI-generated summary
Mrs Cook, a 76-year-old woman, died in January 2010 from hospital-acquired pneumonia, multiple organ dysfunction, and small bowel obstruction. She was admitted to a rural hospital with acute renal failure and dangerously high potassium levels (8.1 and 7.6 mmol/L). Despite clear evidence of severe illness requiring urgent transfer to a tertiary centre, she remained at the rural hospital for approximately 24 hours. The treating general practitioner failed to recognise the urgency, did not adequately transfer clinical responsibility, and gave vague instructions ('as soon as possible') to ambulance services rather than specifying priority status. Key failures included: failure to obtain 12-lead ECG monitoring despite critical potassium levels; failure to initiate immediate corrective measures; inadequate communication of clinical severity to ambulance dispatch; and inappropriate involvement of the patient's usual doctor who had no hospital admission rights and no personal knowledge of the acute presentation. The senior surgeon later stated the patient 'probably would have been better off having come to Adelaide a day or two earlier.'
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…
Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…
79y · Male·Urinary tract infection with E coli bacteraemia on a background of ischaemic hyp…
A 79-year-old man with multiple comorbidities attended Whyalla Hospital ED following a fall. Paramedics documented concerning vital signs (tachypnoea, tachycardia, low oxygen saturation, fever) and a history suggestive o…
88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…
An 88-year-old woman with Lewy body dementia, Parkinson's disease and congestive cardiac failure died from acute kidney injury precipitated by severe dehydration in aged care. June 2020 blood tests showed mild hypernatra…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.