Coroner's Finding: Cook, Courtney Liza

Contributing factors

• paracetamol-induced severe hepatic failure
• cerebral oedema as complication of acute liver failure
• failure to administer N-acetylcysteine in ED despite borderline criteria
• failure to obtain planned blood tests on day 2 post-admission
• communication failures between teams regarding patient status
• delay in prioritizing blood test collection (>48 hours)
• unplanned surgery prior to critical blood testing
• history of anorexia nervosa increasing paracetamol toxicity risk
• uncertainty about exact time of ingestion

Coroner's recommendations

1. Revised paracetamol poisoning protocol should explicitly address management in patients with anorexia nervosa or bulimia, explaining that glutathione depletion increases toxicity risk and NAC should be considered accordingly
2. Paracetamol poisoning protocol should emphasize the critical importance of timely blood testing for liver damage in all cases, particularly when NAC is not administered
3. Implement mandatory policy across all South Australian public health networks requiring blood test to measure paracetamol concentration at four hours post admission to hospital, in addition to blood taken at four hours post suspected ingestion time, to serve as failsafe measure
4. Implement mandatory policy across all South Australian public health networks requiring blood tests for liver function (ALT/AST/INR) at 24 hours post admission in all cases of reported or suspected paracetamol overdose exceeding 10 grams, regardless of reported ingestion time or NAC administration
5. Conduct joint education session between Lyell McEwin Hospital ED and Toxicology services to discuss lessons from this case (session was cancelled due to COVID-19)
6. Implement improved handover procedures between shifts to ensure continuity of care for patients with critical follow-up requirements