Inquest into the death of Marilyn Lalara

48y · Female·acute myocarditis resulting from systemic viral infection

A 48-year-old Aboriginal woman with chronic diseases (diabetes, COPD, ischaemic heart disease) presented with ongoing chest infection symptoms across multiple clinic visits between 30 March and 4 April 2010. Despite five presentations to clinic staff, there was no escalation to medical officer consultation, which might have identified myocarditis earlier. On 4 April, she presented severely unwell with dramatically falling haemoglobin and high blood sugar. Although rapidly evacuated to Alyangula clinic where she was assessed as critically ill and awaiting air evacuation to hospital ICU, no aircraft were available due to maintenance, pilot illness, and another category-1 patient. She arrested during waiting and died. The coroner found inadequate escalation protocols at remote clinics, gaps in staff training for point-of-care testing, and insufficient air-medical fleet capacity contributed to her death, though myocarditis is intrinsically difficult to diagnose ante-mortem.