Inquest into the Death of Steele

63y · Male·ruptured abdominal aortic aneurysm

Norman Eric Keith Steele, 63 years old, collapsed at work on 28 May 2004 and was transported to Merredin District Hospital at 9:10am with a presenting complaint of severe abdominal pain (9/10) radiating to his back, dizziness, and sweating. He had a blood pressure of 80/50 by 10am. Despite these critical signs of a time-critical illness, he was not seen by a medical practitioner until 4:20pm—a delay of over 7 hours. The Royal Flying Doctor Service was not contacted for transfer to Perth until 7:25pm, a further 3+ hour delay. He died at 9:05pm from a ruptured abdominal aortic aneurysm. The coroner found that the excessive delays in diagnosis and transfer contributed materially to the death. A significant secondary issue was the discovery that Registered Nurse Debbie Boon fabricated and extensively altered medical records after the patient's death, including rewriting the Emergency Department notes, changing the Recovery-Observation Chart, and altering vital sign recordings in a deliberate attempt to make the patient appear less ill than he actually was. The coroner referred Nurse Boon to the Nurses Board and made recommendations regarding implementation of a Medical Emergency Team (MET) system in rural settings and improved training in telephone diagnosis consultation for rural doctors.