Coroner's Finding: COOK Eileen Hazel

76y · Female·hospital acquired pneumonia, multiple organ dysfunction and small bowel obstruction with contributing smoking related lung disease

Mrs Cook, a 76-year-old woman, died in January 2010 from hospital-acquired pneumonia, multiple organ dysfunction, and small bowel obstruction. She was admitted to a rural hospital with acute renal failure and dangerously high potassium levels (8.1 and 7.6 mmol/L). Despite clear evidence of severe illness requiring urgent transfer to a tertiary centre, she remained at the rural hospital for approximately 24 hours. The treating general practitioner failed to recognise the urgency, did not adequately transfer clinical responsibility, and gave vague instructions ('as soon as possible') to ambulance services rather than specifying priority status. Key failures included: failure to obtain 12-lead ECG monitoring despite critical potassium levels; failure to initiate immediate corrective measures; inadequate communication of clinical severity to ambulance dispatch; and inappropriate involvement of the patient's usual doctor who had no hospital admission rights and no personal knowledge of the acute presentation. The senior surgeon later stated the patient 'probably would have been better off having come to Adelaide a day or two earlier.'