Finding into death of Mr E
Deceased
Mr E1
Demographics
67y, male
Date of death
2022
Finding date
2022
Cause of death
Fulminant liver failure
AI-generated summary
A 67-year-old man presented to his GP with discoloured urine. Blood tests revealed acute liver toxicity but critical results were communicated via facsimile, with unclear timing of GP's review. The patient deteriorated rapidly and presented two days later in severe hepatic failure. Despite aggressive supportive care at hospital, he died of fulminant liver failure. The coroner found the underlying cause of liver failure remained unexplained despite post-mortem investigation. While facsimile communication of results posed risks, the coroner concluded the liver failure was so severe and rapidly progressive that earlier recognition would likely not have prevented death. The case highlights dangers of outdated communication systems in medicine.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Delayed recognition of abnormal blood results communicated via facsimile
- Unclear timing of GP's review of critical pathology results
- Two-day delay between initial presentation and emergency re-presentation
Coroner's recommendations
- Timboon Medical Clinic Practice Manager should discontinue use of facsimile for receipt of pathology results and institute a digital critical test result management system incorporating closed loop communication to ensure receipt and understanding of communicated material
- Safer Care Victoria and the Department of Health should consider whether all health services should review channels of communication to address potential issues and harms from continued use of facsimile in medical settings
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