Inquest into the Death of Amanda Dana TAUAI
Delivered on :25 May 2015
Delivered at : Perth
Finding of : Deputy State Coroner Vicker
Recommendation No. 1
I recommend clinicians in remote settings consider their capacity to resuscitate patients with sepsis, when assessing a patient’s clinical presentation and the threshold for the administration of broad spectrum antibiotics, following the taking of bloods for diagnostic purposes.
Recommendation No. 2
I recommend additional education and audits on use of the AORC in Paraburdoo to ensure appropriate use of those charts.
Recommendation No. 3
I recommend user friendly flow charts summarising the guidelines and procedures in operation in rural and remote health services for the successful collection of bloods be placed in collection areas where they are not already in existence.
Orders/Rules : N/A
Suppression Order : N/A
Summary : The deceased was 21 years of age at the time of her death, working in Paraburdoo, when she became unwell and presented at Paraburdoo Hospital on 13 March 2012. She was admitted and treated for dehydration and gastroenteritis. She initially responded well to rehydration, but on late evening of 14 March 2012 she began to deteriorate. In the early hours of 15 March 2012 the deceased’s blood pressure dropped significantly, with an elevated heart rate.
The deceased was transferred to Royal Perth Hospital by Royal Flying Doctor Service and treated with antibiotics. She was suspected as suffering from sepsis with cardiac, renal and liver impairment. The deceased was transferred to ICU with suspected toxic shock on 16 March 2012 where, despite aggressive treatment she died early on 17 March 2012.
The issues which were explored at the inquest hearing included the management provided to the deceased while at the Paraburdoo Hospital and whether there was a clear indication to commence giving the deceased antibiotic therapy earlier in her illness. The difficulties of providing medical care in a remote setting were considered.
The Coroner found the deceased died as a result of multiple organ failure due to undefined sepsis (toxic shock syndrome) and that death arose by way of natural causes.
The Coroner made recommendations supporting the consideration of broad spectrum antibiotics to be given at an earlier point, as part of the clinical judgment, taking into account the delay in the obtaining of blood analysis results and the lack of facilities available in the remote setting for intensive resuscitation.
Catch Words : Multiple Organ Failure : Availability of Blood Results : Administering of antiobiotics : Natural Causes.
Last updated: 27-Apr-2016
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