Finding into death of BT
Deceased
BT
Demographics
25y, male
Date of death
2019-04-19
Finding date
2021-03-19
Cause of death
Multiple system failure and ingestion of sodium nitrite
AI-generated summary
BT, a 25-year-old man with bipolar affective disorder and long-standing depression, died from intentional sodium nitrite ingestion while an inpatient in the Behavioural Assessment Unit at Royal Melbourne Hospital. He presented to the ED with suicidal ideation and was admitted for overnight observation. He smuggled sodium nitrite into his room and ingested it at 10:03pm. He deteriorated to cardiac arrest at 10:26pm. The critical delay in treatment occurred because venous blood gas results showing severely elevated methaemoglobin (70-86%) were not configured to display reference ranges and were not transmitted to the laboratory information system, so the abnormal result was not recognized until 12:22am when an arterial blood gas was processed. Methylene blue treatment was thus delayed by nearly 2 hours, missing the window for potentially preventing hypoxic brain injury. The hospital has since implemented automated flagging of abnormal methaemoglobin levels. Clinician education about methaemoglobinaemia recognition is essential given increasing sodium nitrite suicides.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Delay in recognition of methaemoglobinaemia from venous blood gas results
- Point of care analyser not configured to display reference ranges
- Venous blood gas results not transmitted to Laboratory Information System
- Sodium nitrite is an unusual poison not routinely considered in emergency medicine
- High degree of clinical suspicion required to identify sodium nitrite as causative agent
- Opportunity to administer methylene blue in critical timeframe was missed
Coroner's recommendations
- Distribution of this finding to the Australasian College for Emergency Medicine and Safer Care Victoria for education purposes regarding methaemoglobinaemia recognition and management
- Ensure clinicians consider the possibility of methaemoglobinaemia in patients presenting after intentional overdose with dark-appearing blood, cyanosis, hypoxia, and hemodynamic instability
- Educate clinicians on immediate administration of methylene blue for suspected sodium nitrite toxicity
- Continue implementation and monitoring of automated alerting systems for abnormal methaemoglobin levels on both point-of-care analysers and Laboratory Information System
- Ensure all blood gas results including venous samples are transmitted to and displayed in the Laboratory Information System with reference ranges
- Coroners should prioritize investigation of sodium nitrite suicide sources and methods to develop evidence base for future prevention recommendations
- Consider education regarding availability and accessibility of sodium nitrite online and through workplace sources
- Develop awareness strategies among healthcare workers across industries where sodium nitrite is stored regarding safe storage practices
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