Coronial
WAhospital

Inquest into the Death of Troy

Deceased

Josephine Wilma Troy

Demographics

63y, female

Date of death

2006-02-14

Finding date

2012-03

Cause of death

Intra-cerebral bleed secondary to thrombocytopenia in a person with prolymphocytic leukaemia previously treated with chemotherapy

AI-generated summary

Josephine Troy, 63, died on 14 February 2006 at Bunbury Regional Hospital from an intracerebral bleed secondary to thrombocytopenia (platelet count of 1) arising from prolymphocytic leukaemia. She had been in remission following chemotherapy in 2004 but relapsed in January 2006. On 12 February, she presented to Bunbury Regional Hospital ED with fever (38.8°C) and was admitted to St John of God Hospital Bunbury for neutropenic sepsis treatment. A critical miscommunication occurred: her treating haematologist at Fremantle Hospital expected her to remain in the metropolitan area during intensive monitoring, but she returned home to Bunbury. When platelets were urgently needed on 13 February, the order was not marked urgent and delivery was delayed overnight. Early on 14 February she suffered an intracranial bleed; platelets arrived at 9:50am and were transfused but she continued to deteriorate. The coroner found the primary cause was a natural complication of her leukaemia and treatment, but identified two critical miscommunications: confusion over the meaning of 'home' (Bunbury vs Fremantle) and lack of understanding about urgent platelet delivery procedures. Several recommendations were made to improve communication, patient records, and blood product access for regional hospitals.

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

Specialties

haematologyintensive careemergency medicinegeneral medicineoncology

Error types

communicationdelay

Drugs involved

chemotherapy

Clinical conditions

prolymphocytic leukaemianeutropenic sepsisthrombocytopeniapancytopeniafebrile neutropeniaintracranial haemorrhage

Procedures

blood transfusionplatelet transfusionCT scan

Contributing factors

  • Very low platelet count (1) due to relapsed prolymphocytic leukaemia and chemotherapy
  • Delay in platelet transfusion - order not marked urgent, delivery delayed overnight
  • Patient located in regional area (Bunbury) rather than metropolitan centre at time of medical crisis
  • Miscommunication regarding expected patient residence during intensive monitoring period - treating team expected her in Fremantle, she remained in Bunbury
  • Lack of clear communication about urgency of remaining accessible to treating consultant during vulnerable treatment period
  • Treating doctors not aware she was driving from Bunbury for daily blood tests
  • Inaccurate diagnosis recorded in admission notes (CLL instead of PLL) due to patient's own misunderstanding

Coroner's recommendations

  1. Febrile Neutropenia Cards should provide current diagnosis to enable unexpectedly treating practitioners more ready access to patient history and prognosis
  2. Introduce 'Medical Smart Cards' to clarify diagnoses and treatment history for unexpectedly treating medical practitioners
  3. Alternatively, if Medical Smart Cards cannot be introduced, provide hard copy patient diaries for cancer/chemotherapy patients such as those now used by SJOGHB, in conjunction with Febrile Neutropenia Card to ensure patients understand diagnosis and treatment regime
  4. Fremantle Hospital Haematology Day Clinics should require progress notes be completed by medical practitioners immediately following patient review to ensure staff are aware of patient's current status
  5. Patients provided with Febrile Neutropenia Cards should be specifically advised in writing it is preferable they remain accessible to their treating clinic at times of vulnerability in treatment
  6. Regional Hospitals should establish appropriate protocols and procedures for treatment of cancer/chemotherapy patients who may need urgent blood products, taking into account their individual location
  7. Medical Scientists in remote areas should inform treating doctors of relevant time-lines for provision of specified blood products to their location when discussing blood pathology and product ordering
  8. Introduce a tool for remote areas similar to that produced by ARCBS for Bunbury for processing requests for urgent blood products
Full text
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