Inquest into the Death of Morgan

Contributing factors

• Viral infection of heart muscle and pericardium
• Previous pneumonia in October 2001 that depleted immune system
• Failure to diagnose myocarditis and pericarditis prior to death
• Lack of advanced cardiac diagnostic capability at regional hospital
• Communication breakdown between RFDS and treating doctor
• Downgrade of doctor-accompanied transfer without consulting treating physician
• Inadequate equipment on non-doctor accompanied aircraft for critically ill patient
• Delay in intubation and stabilisation prior to transfer

Coroner's recommendations

1. In cases where a specific transfer priority has been arranged in consultation with a treating doctor, a decision to downgrade the transfer should preferably not be made by RFDS without input from the treating doctor concerned, especially in cases with no diagnosis or clear indication of the problem with the patient.
2. The Health Department should consider providing more advanced RFDS-compatible equipment in country hospitals for use by doctors in emergencies, particularly life support equipment such as mechanical ventilators and critical care apparatus.
3. Country hospitals should have access to equipment compatible with RFDS aircraft to facilitate optimal transfers of critically ill patients, reducing reliance on improvisation and suboptimal standards during aeromedical retrieval.