Inquest into the Death of Nielson, Melissa Ann

24y · Female·hypoxic brain injury following unexplained cardiorespiratory arrest

A 24-year-old female with brittle Type 1 diabetes and multiple comorbidities presented to Joondalup ED with a rapidly spreading blistering rash on 3 September 2009. Dr C. appropriately identified a potentially serious dermatological emergency and arranged urgent transfer to Royal Perth Hospital (RPH), which had dermatology expertise and knowledge of her complex history. However, critical communication failures and system delays undermined this appropriate clinical decision. The patient was triaged as ATS 3 at RPH despite pathology indicating ATS 2 was appropriate; the triage nurse did not review the JHC discharge letter detailing abnormal renal function and inflammatory markers. The patient was placed in an unmonitored minor theatre without vital signs being recorded. She arrested unwitnessed 42 minutes after arrival, suffering catastrophic hypoxic brain injury from which she did not recover. Key failures: EDIS misspelling of surname prevented information integration; transfer documentation was initially separated from the patient; triage and placement decisions lacked critical pathology context; delayed ambulance transfer (3+ hours) meant initial blood results were 6 hours old on arrival. Earlier clinical assessment, appropriate triage, cardiac monitoring, and better information communication could have enabled timely recognition of deterioration.