Inquest into the death of Melissa King

33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiopulmonary arrest and resuscitation. Chronic alcoholism with liver disease and malnutrition with re-feeding syndrome were also significant conditions contributing to the death

Melissa King, aged 33, died from hypoxic ischaemic encephalopathy following in-hospital cardiopulmonary arrest at Blacktown Hospital. She presented with severe malnutrition, electrolyte derangements including hyponatraemia, and alcohol-related liver disease. Expert review identified multiple clinical and systemic failures: inadequate micronutrient replacement (particularly thiamine), unappreciated gross fluid and sodium overload despite evident signs including pulmonary oedema and ascites, premature transfer from ICU to ward despite objections from treating teams with breakdown in communication, and failure to review a deteriorating patient in the ward despite nursing requests. The glycoprep bowel preparation for endoscopy likely accelerated decompensation. The coroner found systemic issues including incomplete transfer summaries, lack of verbal handover, abolished after-hours communication systems, and altered MET criteria not communicated to receiving team. The hospital implemented extensive reforms including new discharge protocols, verbal handovers, structured ward reviews within one hour, new emergency response systems, and additional senior medical staffing.