Coronial
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Coroner's Finding: WHISKEY Louise Kitty

Deceased

Louise Kitty Whiskey

Demographics

51y, female

Date of death

2017-09-07

Finding date

2020-11-03

Cause of death

community acquired pneumonia

AI-generated summary

Louise Kitty Whiskey, a 51-year-old Aboriginal woman with chronic alcohol misuse, cirrhosis, and recurrent respiratory infections, died from community-acquired pneumonia at Royal Adelaide Hospital. She was admitted on 23 August 2017 with aspiration pneumonia and displayed aggressive behaviour necessitating an Inpatient Treatment Order. On 6 September, her condition deteriorated rapidly with sepsis, requiring ICU admission and intubation. During treatment, an Acomed infusion pump failed silently, temporarily compromising noradrenaline delivery when her blood pressure was critically low (60 mmHg systolic). Despite manual administration resumption and maximal vasopressor support, she arrested at 7:06 am on 7 September. A review panel concluded the pump failure did not contribute to death, as her underlying cardiac dysfunction and septic shock were the primary cause. The coroner found detention lawful, care appropriate, and no recommendations were warranted.

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Specialties

intensive carepsychiatrygeneral surgeryemergency medicine

Error types

system

Drugs involved

noradrenalineadrenalinevasopressin

Clinical conditions

community-acquired pneumoniaaspiration pneumoniasepsisseptic shockleft ventricular systolic dysfunctionacute kidney injury requiring dialysisalcohol withdrawal seizureliver cirrhosisrefractory hypotension

Procedures

intubationarterial line insertiondialysis catheter insertiondialysisbedside echocardiogramcardiopulmonary resuscitation

Contributing factors

  • chronic alcohol misuse
  • liver cirrhosis
  • recurrent respiratory infections
  • sepsis with suspected secondary source
  • left ventricular systolic dysfunction with global hypokinesia
  • refractory hypotension despite maximal vasopressor support
  • temporary infusion pump failure resulting in interrupted noradrenaline delivery
Full text

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