Coronial
VIChospital

Finding into death of Allison Judith Allan

Deceased

Allison Judith Allan

Demographics

43y, female

Date of death

2015-11-03

Finding date

2019-07-30

Cause of death

Hypoxic ischaemic brain injury resulting from alcohol and sodium valproate toxicity

AI-generated summary

43-year-old woman with epilepsy and depression died from hypoxic ischaemic brain injury after ingesting 15g sodium valproate and 750ml vodka. Critical failures occurred across multiple settings: VPIC provided incomplete advice without recommending serial serum levels; PDH staff inadequately monitored neurological status during a 2-hour gap, failed to escalate deterioration to senior staff, and over-relied on initial VPIC guidance; WBH delayed dialysis initiation by >24 hours despite clear indicators (cerebral oedema, cardiovascular instability, metabolic acidosis). Early intubation at PDH, prompt senior escalation, early toxicology consultation, and timely dialysis at WBH could have prevented death. Systemic issues included VPIC staffing shortages and communication failures between health services.

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

Specialties

emergency medicineintensive caretoxicologypsychiatrygeneral practice

Error types

diagnosticcommunicationsystemdelay

Drugs involved

sodium valproatealcoholdesvenlafaxinemorphinemidazolam

Clinical conditions

sodium valproate toxicityalcohol toxicityvalproate-induced hyperammonaemic encephalopathycerebral oedemalactic acidosishyperammonaemiahypernatraemiacardiac arrhythmiahypoxic ischaemic encephalopathyepilepsydepressionsuicidality

Procedures

intubationmechanical ventilationcontinuous renal replacement therapyCT brain scanMRI brain scan

Contributing factors

  • Inadequate neurological observations by nursing staff at PDH during critical 2-hour period
  • Failure to recognise and escalate clinical deterioration to senior staff at PDH
  • Delayed intubation despite GCS decline to 7-8
  • Over-reliance on initial VPIC advice despite patient deterioration
  • Incomplete VPIC advice lacking recommendation for serial serum valproate levels
  • VPIC pharmacist under significant workload pressure with 63 calls in 6.5 hours
  • Delayed internal VPIC call review (11.5 hours post-consultation)
  • Absence of continuous monitoring at PDH between 10.30pm-12.45am
  • Assumption that alcohol was primary cause of drowsiness, underappreciating valproate toxicity
  • WBH delayed commencement of dialysis by >24 hours despite clear indicators
  • Lack of toxicology consultation at WBH ICU on admission
  • WBH reliance on St Vincent's Hospital ICU consultant advice rather than toxicology specialist
  • Possible respiratory compromise during unmonitored periods at PDH
  • Inadequate transfer of critical information (CT brain scan results) between PDH and WBH

Coroner's recommendations

  1. PDH implement change whereby medical staff make initial contact with VPIC, but review this to allow triage nurse early toxicological advice if doctor unavailable
  2. PDH review arrangements with pathology services regarding after-hours capacity
  3. PDH enter into memorandum of understanding with nearest higher-level healthcare service regarding escalation of potentially deteriorating toxicology patients, with consultant-to-consultant communication
  4. PDH and WBH provide internal education to medical staff on: importance of utilising VPIC as primary resource for overdose management when lacking clinical toxicology background; re-consulting VPIC for ongoing concerns or deviation from expected clinical course; including these recommendations in relevant policies
  5. St Vincent's Hospital Melbourne on-call ICU consultants recommend utilisation of VPIC service as primary resource for drug overdose and poisoning patients in their informal advice arrangements with WBH
  6. Department of Health and Human Services address VPIC staffing shortage through provision of additional funding
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