Finding into death of Elsa Harrington
Deceased
Elsa Harrington
Demographics
45y, female
Date of death
2002-11-13
Finding date
2012-03-02
Cause of death
Multisystem organ failure secondary to acute liver failure associated with paracetamol toxicity
AI-generated summary
Elsa Harrington, a 45-year-old woman, died from acute liver failure secondary to paracetamol toxicity in November 2002. She was admitted post-hysterectomy with bowel obstruction and underwent adhesion surgery. Following surgery, she received therapeutic doses of paracetamol and developed abnormal liver function tests on 8 November. However, clinicians failed to recognise these as paracetamol-related, instead attributing them to post-operative complications. Critical failures in communication and handover meant senior consultants were not notified of her deteriorating condition until Sunday, 48+ hours later. Her mental status changes (reflecting early hepatic encephalopathy) and reduced urine output were not recognised as indicators of acute liver failure. While paracetamol toxicity at therapeutic doses was poorly recognised in the medical literature at that time, earlier recognition of abnormal liver function tests, discontinuation of paracetamol, and prompt escalation to senior clinicians might have allowed earlier N-acetylcysteine treatment. The coroner identified systemic failures in communication, handover practices, and the lack of holistic clinical assessment as contributing factors.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Failure to recognise abnormal liver function tests as paracetamol-related toxicity
- Continued prescription of paracetamol despite elevated liver enzymes
- Poor communication between intern, registrar and consultant
- Failure to escalate clinical concerns to senior clinicians
- Inadequate handover of clinical information between covering doctors
- Lack of holistic assessment of clinical deterioration
- Failure to follow-up on previously ordered investigations
- Failure to recognise signs of hepatic encephalopathy (altered mental status)
- Limited awareness in medical profession of paracetamol toxicity at therapeutic doses
- After-hours staffing model limiting continuity of care
Coroner's recommendations
- Commend the work of Dr L. and colleagues for highlighting the risk of accidental paracetamol poisoning in the Medical Journal of Australia
- Recommend that the Australian Medical Association (AMA Victoria) and the College of General Practitioners collaborate to implement a medical profession and public awareness raising program regarding the risks of accidental paracetamol poisoning
- Recommend that the Therapeutic Goods Administration (TGA) update their bulletins and alerts on the risks associated with accidental paracetamol poisoning and consider mandating improvements to consumer information regarding these risks
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