Coronial
WAhospital

Inquest into the death of Amanda Dana TAUAI

Deceased

Amanda Dana TAUAI

Demographics

21y, female

Date of death

2012-03-17

Cause of death

Multiple organ failure due to undefined sepsis (toxic shock syndrome)

AI-generated summary

Amanda Dana Tauai, 21 years old, died from septic shock with multi-organ failure in March 2012 after presenting with symptoms initially consistent with viral gastroenteritis and dehydration. Initial management at remote Paraburdoo Hospital was appropriate, but critical clinical deterioration occurred 10pm on 14 March when her blood pressure declined significantly. Dr M. was not notified of this critical observation. When contacted at 2:05am on 15 March about ongoing vomiting, he initially managed her as hypovolemic shock with fluids and dopamine. Broad-spectrum antibiotics were not administered in Paraburdoo because Dr M. believed the presentation was viral, not bacterial. Full blood picture results showing elevated neutrophils (suggesting bacterial infection) were not available until after transfer. Expert review suggests earlier blood cultures and empirical antibiotics at 3am on 15 March (after vital sign abnormalities documented) may have improved outcomes, though this remains uncertain. Key failures included failure to escalate a critical 10pm blood pressure reading and delayed diagnostic results typical of remote settings.

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

Specialties

general practiceemergency medicineintensive care

Error types

diagnosticcommunicationdelay

Drugs involved

metoclopramidehyoscine butylbromideparacetamolpantoprazoleondansetronhyoscine butylbromideprochlorperazinedopaminenoradrenalineceftriaxonebroad spectrum antibiotics

Clinical conditions

septic shocktoxic shock syndromegastroenteritisdehydrationhypotensionmulti-organ failureacute renal impairmenthepatic impairmentmetabolic acidosispelvic infectionleukocytoclastic vasculitisthrombocytopenia

Procedures

intravenous cannula insertionindwelling catheter insertiondopamine infusionnoradrenaline infusionvenovenous haemodiafiltrationintubation and mechanical ventilationechocardiographyarterial blood gas analysis

Contributing factors

  • Delayed availability of full blood picture results
  • Failure to escalate critical blood pressure reading at 10pm on 14 March
  • Misdiagnosis of bacterial sepsis as viral gastroenteritis
  • Lack of empirical antibiotic therapy despite signs consistent with sepsis in early hours of 15 March
  • Remote location with limited diagnostic and resuscitation facilities
  • Delay in blood sample transport to pathology laboratory
  • Incomplete medical observations documentation (AORC)
  • Clinical judgment threshold for antibiotics too high in remote setting without real-time diagnostic support

Coroner's recommendations

  1. Clinicians in remote settings should consider their capacity to resuscitate patients with sepsis when assessing a patient's clinical presentation and threshold for administration of broad spectrum antibiotics, following the taking of bloods for diagnostic purposes
  2. Additional education and audits on use of the Adult Observation and Response Chart (AORC) in Paraburdoo to ensure appropriate use of those charts
  3. User friendly flow charts summarising guidelines and procedures in operation in rural and remote health services for the successful collection of bloods should be placed in collection areas where they are not already in existence
Full text
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