Coronial
VIChospital

Finding into death of Shane Kyle Tatti

Deceased

Shane Kyle Tatti

Demographics

27y, male

Date of death

2014-11-08

Finding date

2018-08-21

Cause of death

Complications of snake bite

AI-generated summary

Shane Kyle Tatti, a 27-year-old gardener, died from complications of tiger snake envenomation. After a vigorous bite on 6 November 2014, he received one vial of tiger snake antivenom at Orbost Hospital 62 minutes post-bite, consistent with then-current guidelines. Despite appropriate initial management and rapid transfers to Bairnsdale and Austin Hospitals, he developed severe progressive myotoxicity, rhabdomyolysis, coagulopathy, renal failure and shock, dying 2 days later. The coroner found conflicting expert opinion: two toxicologists questioned whether single-dose antivenom was adequate for severe envenomings, while the guideline author argued the massive venom load caused irreversible muscle damage before antivenom could act. The case highlights uncertainty around optimal antivenom dosing in extreme envenoming cases and the tension between evidence-based population guidelines and individual clinical outliers.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

emergency medicinetoxicologyintensive carepathology

Error types

possibly diagnostic - uncertainty regarding adequacy of venom neutralisationpossibly medication - debate over antivenom dosing

Drugs involved

tiger snake antivenombrown snake antivenommetoclopramidepromethazine

Clinical conditions

snake envenomation (tiger snake)consumption coagulopathyneurotoxicitythrombotic microangiopathymyotoxicityrhabdomyolysisacute renal failurehyperkalaemiashock

Procedures

fasciotomy

Contributing factors

  • tiger snake envenomation with massive venom load
  • potentially inadequate antivenom dosing (single vial vs. multiple vials)
  • rapid toxin movement to muscle causing irreversible myotoxicity prior to antivenom administration
  • severe myotoxicity leading to rhabdomyolysis with peak CK >500,000
  • severe coagulopathy (INR >10, APPT >120)
  • acute renal failure with hyperkalaemia
  • refractory shock

Coroner's recommendations

  1. DHHS should again review the 2017 'Management of snake bite in emergency departments in Victoria clinical guidelines' in light of this Finding
  2. The Australasian College for Emergency Medicine (ACEM) should circulate this Finding to ACEM fellows to highlight the evidence, guidelines and potential issues in the management of snake bite
  3. Support for multi-centre, independent research to substantiate the appropriateness of single ampoule antivenom dosing
  4. Clinical details of this case and other tiger snake envenomation deaths should be published in medical literature (subject to family consent) to inform clinicians
  5. Guidelines should acknowledge potential circumstances where more than one ampoule of antivenom may be required, particularly in severe envenoming cases
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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