Inquest into the Death of Robson

Contributing factors

• Failure to diagnose Addison's Disease despite prolonged symptoms
• Inadequate supervision of trainee doctor (Dr W.) managing seriously unwell patient
• Patient and family not informed of trainee doctor status
• Clinical signs of Addison's Disease not recognised (skin pigmentation, severe fatigue, weight loss, vomiting)
• Lack of specialist referral for undiagnosed serious illness
• Inadequate response by senior doctor when fainting episode reported
• Inappropriate discharge from hospital without medical review or admission
• Lack of communication about follow-up appointment after hospital discharge
• Initial misattribution of symptoms to glandular fever and depression

Coroner's recommendations

1. Arrangements for pre-vocational doctors in general practice should include specified criteria for referral of very unwell patients to supervising practitioners, including cases where illness has significantly altered quality of life, impacted work/schooling, or caused significant physical changes such as weight loss indicating being underweight.
2. Before patients are seen by a trainee doctor undertaking prevocational training, patients should be informed of the doctor's medical status and informed consent obtained.
3. Issues raised by this case should be discussed with relevant general practitioner bodies and the Health Department of WA, with emphasis on management of patients with serious undiagnosed illness, and outcomes disseminated to all general practitioners and specialist groups.
4. Steps should be taken to ensure general practitioners can seek and obtain assistance from relevant specialists when managing patients with serious undiagnosed illness through referral, telephone contact, or patient transfer to appropriately staffed hospitals, with urgent access to on-call specialists at tertiary hospitals.
5. Particular attention should be given to developing mechanisms to ensure serious illness is recognised by general practitioners and nursing staff through continuing educational activities.
6. Staffing procedures at Albany Regional Hospital and similar facilities should be reviewed to ensure seriously ill patients are identified and not discharged until a medical management plan has been formulated and enacted.
7. Consider development of permanent medical presence or mixed staffing model at Albany Regional Hospital to provide more extensive immediate coverage.