Finding into death of June Dianne Owen
Deceased
June Dianne Owen
Demographics
63y, female
Date of death
2008-01-22
Finding date
2011-04-08
Cause of death
Cardiomegaly and biventricular dilatation
AI-generated summary
A 63-year-old woman with severe cardiac disease (cardiomegaly, biventricular dilatation, and chronic cardiac failure) presented to a rural emergency department with recurrent abdominal pain on 21 January 2008. She was assessed by nursing staff who requested the on-call doctor attend. The doctor made her assessment by telephone and declined to attend in person. The patient received pethidine (opioid analgesic) and was discharged after 40 minutes when her pain resolved. She died at home shortly after arrival, with autopsy confirming cardiomegaly and biventricular dilatation as the cause. Critical issues in care: absence of physician examination of a severely compromised cardiac patient despite nursing request; phone-based assessment and clinical decision-making; discharge after opioid administration without admission for monitoring. The hospital operated without resident medical staff, relying on contracted on-call general practitioners.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Failure of on-call doctor to physically examine patient at emergency department despite nursing request
- Phone-based clinical assessment and decision-making without in-person evaluation
- Assessment by nursing staff only despite known severe cardiac disease
- Discharge after opioid analgesic administration without admission for monitoring
- Inadequate risk stratification for patient at documented risk of sudden cardiac death
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