Coronial
VIChome

Finding into death of Minh Thao La

Deceased

Minh Thao La

Demographics

48y, male

Coroner

Deputy State Coroner Paresa Spanos

Date of death

2016-11-26

Finding date

2018-11-09

Cause of death

hypoxic ischaemic encephalopathy, complicating cardiac arrest in the setting of asthma

AI-generated summary

A 48-year-old man with known asthma and high sensitivity to rye grass pollen died from hypoxic ischaemic encephalopathy following cardiac arrest during the November 2016 Melbourne thunderstorm asthma epidemic. He became acutely unwell at 7:20 pm with severe respiratory distress, family called '000' immediately and performed CPR. Ambulance response was timely in unprecedented circumstances; however, he sustained severe hypoxic brain injury and died 5 days later. Clinical lessons include: all asthmatics need written action plans and appropriate preventer medications (not just reliever); hay fever sufferers warrant allergy testing and preventive therapy; those at risk should remain indoors during TA warnings. The coroner noted his lack of documented asthma management plan, sub-optimal preventer use, and no documented hay fever treatment despite post-mortem evidence of high rye grass sensitisation.

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

Specialties

emergency medicineparamedicinerespiratory medicineallergy and immunologypathology

Error types

system

Drugs involved

salbutamolbretaris

Clinical conditions

asthmaallergic asthmahay feverallergic rhinitisrespiratory arrestcardiac arresthypoxic ischaemic encephalopathybronchospasmthunderstorm asthma

Procedures

cardiopulmonary resuscitationintubationmechanical ventilationpost-mortem CT scanning

Contributing factors

  • Thunderstorm asthma event - rye grass pollen exposure
  • High sensitisation to rye grass pollen (RAST 54.10 kUA/L)
  • Sub-optimal preventer medication use
  • No documented asthma action plan
  • Possible additional sensitisation to Alternaria mould
  • Exposure at window when thunderstorm occurred
  • Limited family communication regarding asthma status to treating doctors

Coroner's recommendations

  1. Further research into the specific meteorological, biological and aerobiological factors that create thunderstorm asthma events to improve prediction and forecasting
  2. Continued verification and development of the thunderstorm asthma forecasting system
  3. Continuation of DHHS public awareness campaigns, asthma action plan promotion, and education regarding the hay fever-thunderstorm asthma link
  4. Further medical and allied health education encouraging hay fever sufferers to undergo allergy testing and develop specific management plans
  5. Community education to remain indoors with windows shut and turn off evaporative cooling during thunderstorm asthma warnings
  6. Highlight the outstanding issue regarding provision of estimated ambulance arrival times to callers to enable informed decision-making about alternative transportation during surge events
Full text

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.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.