Finding into death of Gail Fergusson

Contributing factors

• Failure of Melbourne Pathology to telephone abnormal liver function results to treating physician despite exceeding laboratory's own critical notification threshold
• Pathology results faxed to emergency department but not communicated verbally to treating emergency physician
• Unknown person placed pathology report in medical file without bringing abnormal results to attention of clinician
• Patient transferred to ward without emergency physician reviewing abnormal LFT results
• Lack of robust handover and communication between departments regarding abnormal pathology results
• Delayed recognition of paracetamol overdose due to lack of awareness of critical results
• Patient ingested large quantity of paracetamol (approximately 100 Panadeine tablets) over several hours before hospital presentation
• N-acetylcysteine administered only after liver damage already established (too late, as must be given within 24 hours of ingestion)
• Complex medical presentation with multiple confounding issues (fracture, diabetes, alcohol history, infection) obscured the paracetamol overdose diagnosis

Coroner's recommendations

1. Epworth Hospital should implement robust pathology and radiology result follow-up protocols with allocated staff member responsible for signing off results daily
2. All abnormal results must have lowered thresholds for notification and treating doctors must be made aware before patient discharge
3. Pathology laboratories should have consistent procedures for immediate telephone notification of critical values in accordance with laboratory-specific critical intervals
4. Improved handover and communication processes between departments are essential to ensure abnormal findings are not lost during patient transfers
5. Electronic patient management systems should track whether abnormal results have been noted and actioned
6. Clinicians should understand the limitations of eGFR testing in unstable patients and not rely on these tests as reliable indicators of renal function in such circumstances
7. Early Medical Emergency Response Systems should be established in hospital inpatient environments to identify deteriorating patients earlier
8. Filing and notification processes for pathology results should be improved to prevent results being lost during patient transfers between departments