Coroner's Finding: FENSOM Angela Catherine and TAANKINK Johaanes Andrew

Unknown·Ms Fensom: influenza A (H1N1 2009, pandemic swine flu) with myocarditis causing cardiac failure. Mr Taankink: hypoxic respiratory failure, H1N1 pneumonitis, acute respiratory distress syndrome

Two deaths from H1N1 influenza in 2009. Ms Fensom (41) died from myocarditis complicating swine flu after inadequate recognition and management of persistent hypotension at Millicent Hospital. Her condition required escalation to inotropic support and tertiary ICU care from at least mid-morning on 18 August, but the treating registrar (Dr V.) failed to recognise the seriousness of persistently low blood pressure despite it not responding to fluid therapy. Mr Taankink (26), an asthmatic, was prescribed Tamiflu on 6 August but did not fill it; if filled within 48 hours, pneumonia development might have been prevented. After admission on 10 August with pneumonia, he required intubation and mechanical ventilation by 11 August evening (24 hours earlier than it occurred), with prompt retrieval to tertiary ICU. Confusion about clinical responsibility between two physicians and reluctance to escalate care after hours contributed to delayed intervention.