Inquest into the Death of nilon

67y · Female·Pneumonia (streptococcus pneumoniae) in a woman receiving treatment for carcinoma of the lung and emphysema

Peggy Anne Nilon, 67, died from pneumonia (streptococcus pneumoniae) at St John of God Hospital Bunbury on 25 February 2003. Her small cell lung cancer had achieved remission following chemotherapy and radiotherapy. A critical error occurred when a Hospice Referral Form at Mount Hospital incorrectly stated she was in 'terminal phase' and had cerebral metastases. This form was not reviewed by her oncologist Dr van Hazel before signing medications. The deceased was subsequently assumed to be terminally ill and admitted to inpatient palliative care at Bunbury hospital. Despite her family stating she was in remission, nursing and medical staff disbelieved them. No investigations were performed for acute illness. Her severe pain from pneumonia was treated symptomatically. Dr L. admitted her to palliative care without urgent review, delayed attending for 7 hours, and unilaterally issued a 'not for resuscitation' order without consulting the patient or family. She died without antibiotics for her treatable pneumonia. The coroner found the death could have been prevented with proper diagnosis and treatment, and made recommendations regarding hospice referral forms, palliative care admission procedures, and legislation governing 'not for resuscitation' orders.