Inquest into the death of Lorraine BARNES

85y · Female·sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury to the right lung, dementia, diverticulitis and a urinary tract infection were all significant conditions contributing to Mrs Barnes' death

Lorraine Barnes, an 85-year-old woman admitted to Wollongong Private Hospital for convalescence, died from sepsis with aspiration pneumonitis following iatrogenic lung injury. She developed severe malnutrition and electrolyte disturbances after refusing oral intake from hospital day 5 onwards. A fine-bore nasogastric tube was inserted on 30 April 2016 to provide enteral nutrition but was incorrectly positioned in the right lung due to a hiatus hernia and software error when reviewing chest x-rays (Dr N. and Dr C. reviewed the wrong x-ray image). Concentrated nutritional supplements were inadvertently delivered into the lung, causing perforations. Clinical lessons: (1) Early multidisciplinary case conferences should have been convened; (2) Dietician involvement should have been sought earlier when malnutrition was identified by 24 March; (3) The End-of-Life form lacked clarity distinguishing invasive versus non-invasive nutritional support; (4) Radiology review processes for weekend NGT x-rays needed improvement; (5) Adequate post-discharge services (Community Packages) should have been discussed prior to private hospital transfer.