Finding into death of Lynsie Maree Everett

Contributing factors

• Failure to appreciate severity and complexity of septic condition
• Failure to escalate to intensive care consultation or Adult Retrieval Victoria
• Inadequate fluid resuscitation; patient encouraged to refuse IV fluids despite hypotension
• Misinterpretation of respiratory distress as anxiety and alcohol withdrawal
• Sparse vital sign monitoring overnight despite clinical deterioration
• Modified vital sign observation thresholds that did not trigger appropriate escalation
• Inadequate respiratory support; maximum 15L/min supplemental oxygen insufficient for patient's respiratory demand
• Inappropriate use of sedative medications (diazepam, temazepam) in context of severe respiratory distress
• Failure to recognize and respond appropriately to progressive hypoxia overnight
• Inappropriate resuscitation code called (MET rather than Code Blue)
• No advanced airway support available; on-call anaesthetist unavailable (in theatre)
• Inadequate documentation of airway management attempts during resuscitation
• Underlying congenital chest wall abnormality and difficult intubation status not adequately managed
• Delayed administration of antibiotics (1.5 hours after presentation)

Coroner's recommendations

1. That the Department of Health and Human Services and Safer Care Victoria be informed of the issues identified in Ms Everett's death at Swan Hill District Health, specifically: (a) The severity and complexity of the septic condition was not fully appreciated, leading to care remaining in a rural hospital unsupported by a high dependency or intensive care unit; (b) Medical and nursing staff did not recognise, respond to, or escalate the deteriorating respiratory condition appropriately; (c) Possible contributing factors included assumption that deranged liver function tests were alcohol-related and misinterpretation of respiratory symptoms clouded by familiarity with anxiety symptoms; (d) A MET code rather than Code Blue was called with no doctor present possessing advanced airway skills.
2. That the Department of Health and Human Services Safer Care Victoria strengthen and support Swan Hill District Health by providing required resources and training to address identified issues.