Coroner's Finding: COOK Eileen Hazel
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.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- acute renal failure unrecognised and not adequately treated
- hyperkalaemia with dangerous potassium levels (8.1 and 7.6 mmol/L on 13 January, 6.5 mmol/L on 14 January) not managed
- failure to perform 12-lead ECG monitoring despite critical electrolyte abnormalities
- failure to initiate immediate management of hyperkalaemia (no calcium gluconate, salbutamol, dextrose-insulin given)
- delayed transfer to tertiary hospital - remained at rural hospital >24 hours
- vague communication of transfer priority ('as soon as possible') rather than specific priority classification
- failure to convey clinical severity to ambulance dispatch
- inappropriate cessation of clinical responsibility by treating doctor
- inadequate information transfer to replacement doctor
- failure to follow up blood test results ordered that day
- deteriorating oxygen saturations not acted upon
- professional etiquette dispute preventing continuity of care
Coroner's recommendations
- Eliminate vague arrangements such as 'as soon as possible' from conversations between hospital nursing staff and ambulance services; instead use the SAAS triage priority system with specific priority classification to ensure appropriate urgency is conveyed for patient transfer
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