Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Robert Pearce, Coroner, having investigated a death of

 Norman Valentine BEAMES

Find That : 

(a)        Norman Valentine BEAMES died on or about 11 January 2011 at North West Regional Hospital, 23 Brickport Road Burnie. 

(b)        Mr BEAMES was born at Natone in Tasmania on 21 January 1930 and at the time of his death was aged 80 years. 

(c)        Mr BEAMES’ death was caused by an acute adverse reaction to a contrast agent injected for the purpose of a CT scan. 

Circumstances Surrounding the Death : 

Mr Beames was aged 80.  He and his wife Jean had been married for 61 years and they lived in Devonport.  He was in reasonable health for his age but had early dementia, ulcers on his leg and for some time had been experiencing difficulty swallowing. 

On 10 January 2011 Mr Beames attended the Mersey Hospital at Latrobe with his wife.  The purpose of the visit was so that Mr Beames could undergo a CT scan in an attempt to identify the cause of his swallowing difficulties.  Performance of the CT scan required injection of a contrast solution containing iodine.  Mr Beames had a severe adverse reaction to the solution.  He developed clinical anaphylaxis which led to respiratory and cardiac arrest and a severe injury to his brain.  He died the following day. 

Comments & Recommendations : 

The coronial investigation included an assessment of the nature and extent of the risk to Mr Beames of administration of the contrast solution and whether any other measures could or should have been taken to determine whether there was an increased risk in his case.  I sought information both from the company that supplied the solution and the company that performed the scan. 

The contrast solution injected into Mr Beames’ blood stream was “Isovue”.  The product contains iodine in a non-ionic solution.  It is approved for use in Australia and many other parts of the world.  The risks associated with use of such agents has been the subject of international study.  The Royal Australia and New Zealand College of Radiologists has guidelines for their use.  Acute adverse reactions are extremely rare, even for patients with a history of allergies of asthma.  The risk is greater if there is evidence of a previous reaction to a similar agent. 

Prior to injection of the contrast solution Mr Beams and his wife each signed an information and agreement form.  The answers, nor Mr Beames’ medical history, gave no notice of the presence of any increased risk factors.  The form signed by Mr Beames’ wife warned of a risk of “very rarely more severe allergic reactions that may be life threatening…”.  Mr Beames, by his age and medical condition, may have had a reduced understanding of the document and the nature of the risk.  However I am satisfied that the guidelines were followed and that administration of the solution was appropriate in the circumstances.  The reaction was unexpected and could not reasonably have been foreseen. 

I have decided not to hold an inquest into Mr Beames death because the investigation has sufficiently disclosed his identity, the time, place, cause of death, the relevant circumstances concerning the deaths and the particulars needed to register the deaths under the Births, Deaths and Marriages Registration Act.  I do not consider that the holding of an inquest would elicit any further information and, in the circumstances, is not necessary. 

I convey my condolences to Mr Beames’ family.

DATED     11 October 2011 at Launceston in Tasmania


Robert Pearce