Inquest into the death of Lynette Maree YOUNG

46y · Female·Shock following interferon alpha treatment following removal of a melanoma

Lynette Young, 46, died of shock secondary to pericarditis with cardiac tamponade following interferon alpha treatment for melanoma. She presented with chest pain to Dubbo Base Hospital where multiple clinical failures occurred. Key failures included: inadequate vital sign observations despite Between the Flags policy requiring hourly monitoring in a Category 2 patient; failure to document observations and maintain fluid balance charts in a patient on IV therapy; inadequate handover between shifts; absence of the primary nurse from HDU without proper handover of care; failure to recognise deteriorating signs (undetectable blood pressure, tachycardia, hypothermia) and delayed MET call activation. A locum consultant (Dr R.) did not read progress notes routinely, did not recognise or act on vital sign abnormalities, and issued contradictory orders regarding fluid therapy. Early echocardiography might have identified cardiac tamponade requiring urgent intervention. Systemic improvements have since been implemented.