Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
Rule 11
These findings have been de-identified by direction of the Coroner pursuant to S.57(c) of Coroners Act 1995
I, Timothy John HILL, Coroner, having investigated the death of
Ms W
WITHOUT HOLDING AN INQUEST
Find :
(a) the identity of the deceased is Ms W, who was born interstate in 1996.
(b) Ms W died after contracting H1N1 09 viral pneumonia (swine flu);
(c) Ms W died on the 23 July, 2009 at the Mersey Community Hospital
(d) At the time of her death Ms W was being treated by a medical practitioner.
Circumstances:
Ms W was born with Klippel-Feil syndrome and mild autism. The main symptoms associated with these conditions were a short neck and a learning disability. Klippel-Feil syndrome is characterised by congenital fusion of the cervical vertebrae. It is thought to be a rare condition, but the actual incidence is unknown. The classical features of Klippel-Feil syndrome are a short neck, limitation in range of motion of the neck and a low hairline. A short neck in itself should not increase the risk of complications from a respiratory illness unless there are concerns about upper airway obstruction. This was not the case with Ms W. I also note that Ms W had also undergone surgery for an oesophageal duplication cyst some years ago.
On 17 July, 2009 Ms W was reviewed by Dr Donna Challinor at the City Medical Centre, Devonport after she had been suffering from flu like symptoms for a week. Dr Challinor found that Ms W was, ‘using inappropriate words. Her mother stated that this was not her usual appearance. On examination, I confirmed that Ms W was febrile, up to 41 degrees Celsius that day. She seemed a little weak and required support to stand. I found no abnormality on examination of the ears and throat. There was no obvious nasal congestion. She was photophobic. She complained of upper back pain on neck reflexion. On auscultation of the chest, there were bilateral breath sounds and no accessory muscle use. This examination was essentially normal. I noted a mottled rash from lower abdomen to legs. I was convinced that the rash could be blanched and thought Ms W should be reviewed in the Emergency Department’.
Ms W was taken immediately by her mother to the Emergency Department (EM) at the Mersey Community Hospital. Ms W was examined by Dr Gideon Lurie a locum Paediatrician. Dr Lurie found that Ms W was ‘slightly lethargic, but she still responded appropriately to my questions. Her initial temperature was 40 degrees but had decreased to 37 degrees by the time I saw her. Oxygen saturation was 97% in room air and her heart rate was 100. She had restricted neck movement due to her Klippel feil syndrome but there was no photophobia and no rash. She had a dry tongue and her capillary refill time was slightly reduced to three seconds. There was a left thoracotomy scar. Her chest was clear with normal work of breathing and no clinical evidence of pneumonia. There were normal heart sounds with no murmur. Her abdomen appeared normal’.
Dr Lurie assessed Ms W as having a viral illness (possibly influenza) with mild to moderate dehydration. Dr Lurie admitted Ms W to the ward and ‘I asked for an intravenous cannula to be inserted and intravenous fluids (Iv) started. I ordered blood tests for blood sugar level, electrolytes, urea, creatinine, full blood count. C-reactive protein, creatinine kinase, liver function and blood culture. I also ordered a chest x-ray and nasal and throat swabs for swine flu influenza’.
Ms W disclosed to a nurse that her cousin had ‘swine flu’ however the nurse was unable to contact the family to confirm this.
The results of the various tests conducted were suggestive of a viral process. Dr Lurie at this point decided not to administer Oseltamivir (an antiviral drug that slows the spread of the influenza virus between cells). Dr Lurie states that, ‘I decided not to administer Oseltamivir empirically as Ms W had already been unwell for four days prior to her presentation to hospital. Oseltamivir is most likely to be of benefit if given within 48 hours of symptom onset. At the time of her admission there were no clear guidelines from North West Regional Health as to which children who present later in their illness should empirically receive Oseltamivir, but as Ms W was not seriously unwell I thought it reasonable to wait for her respiratory viral PCR result’.
The following morning Dr Lurie reviewed Ms W again and described her as looking well, alert and interactive. She had a dry cough but was afebrile (no fever) and had no respiratory distress. She remained on intravenous fluids.
Ms W was again reviewed by Dr Lurie on the morning of the 19 July. Dr Lurie found that Ms W, ‘looked well and was tolerating fluids. She was afebrile, her oxygen saturation was 96% in room air with no respiratory distress and her chest was clear. The respiratory viral PCR result was negative for influenza A and swine influenza. Ms W was seen to have improved from the time of admission and was well at the time of discharge from the hospital. I spoke to Ms W’s family on discharge and advised that I expected that she would continue to improve at home, however, if her condition worsened or there were any other concerns then she should return to the emergency department for review. I told them that I would be concerned if she developed breathing difficulty, increased lethargy or her fluid intake was poor. I advised the family to take Ms W to her general practitioner the following day for review’.
Ms W remained at home after discharge from the hospital. Mrs W (mother) states that Ms W’s condition got a little better although she wasn’t eating or drinking much.
In the early hours Thursday 23 July Ms W’s condition started to deteriorate. Mrs W states that, ‘my daughter really started to go downhill. She was moaning and having trouble breathing. She felt cold to touch so I put her in bed with me. I was really concerned so I asked her father to call the ambulance. I heard her father tell the operator (Tasmanian Ambulance Service) that his daughter was having trouble breathing and was hallucinating. While we were waiting for the ambulance my daughter started to have real difficulty breathing so I took into the lounge room. My daughter slid down off the couch and onto the floor. She had her hands and knees on the floor. She had wet herself. I picked her up and immediately noticed that she was not breathing. I screamed out and my son Andrew came out of his bedroom’.
Mrs W indicates that a further telephone call was made to 000 (Tasmanian Ambulance Service) as the ambulance had not arrived 30 minutes after the initial call. A further telephone call 000 (this time to Tasmania Police) was made approximately 10 minutes later as the ambulance had still not arrived. The ambulance arrived about 5 to 10 minutes later.
Ms W was examined by Ms Mary Knowles a Paramedic with the Tasmanian Ambulance Service. Ms Knowles reports that Ms W was, ‘lying supine on the lounge room floor. A male was leaning over Ms W performing CPR. There appeared to be a large quantity of vomitus in Ms W’s airway. I did not observe any cardiac compressions being delivered. I immediately began checking Ms W’s response, airway, breathing and circulation whilst the student paramedic removed defibrillation pads from the cardiac monitor. Ms W was non-responsive, the airway was full of fluid/vomitus, breathing was absent and there was no palpable carotid pulse. The cardiac monitor showed asystole (no heart activity) in leads I/II and III. Ms W’s pupils were fixed and dilated. Her skin was cool to touch and waxen in colour’.
Ms W was transported to the Mersey Community Hospital shortly later but did not recover and passed away at 4.45am that morning.
A post mortem was conducted by Dr Christopher Lawrence (State Pathologist). Dr Lawrence found that Ms W died of H1N1 90 viral pneumonia. Dr Lawrence found that the negative result in the first test for H1N1 could have been due to:
1. ‘sparse organisms in the naso-pharynx, in some reported cases of pulmonary viral pneumonia there are relatively few organisms in the upper airway.
2. Ms W is reported to have hyper-reactive gag reflex and it may have been more difficult to adequately sample the naso-pharynx during life than at post-mortem.
3. Experience of H1N1 09 in other States suggests that in cases with identified H1N1 09 viral pneumonia where multiple sites are sampled some of the swabs are negative.
In retrospect, medically, Ms W should probably have been managed in hospital on the basis of her symptoms rather than on the negative swab result. Treatment with Tamiflu may have prevented her death’.
The response to Ms W’s condition both on the day and in the days prior to her death were the subject of a detailed examination by a medical adverse event panel. The panel sought reports from various medical and allied medical professionals concerning the care provided to Ms W at admission to the Mersey Community Hospital, upon discharge and during the emergency response on the day of her death. During the course of that review process the following matters were considered.
- The management model opted by Dr Lurie in respect to Ms W was a clinical judgement based on the signs and symptoms the patient was displaying.
- The decision to discharge Ms W from hospital following the negative result for H1N1 Influenza 09 was a clinical decision. If a negative result is returned the patient will be treated according to the severity of the symptoms displayed. In the majority of cases, laboratory confirmation of H1N1 Influenza 09 will not change the clinical management of the patient.
- At the time of Ms W’s presentation at the Emergency Department at the Mersey Community Hospital the protocol for swabbing for H1N1 was developed in consultation with the Royal Hobart hospital and the microbiology laboratory of the North West regional Hospital. The swabs obtained from Ms W were in accordance with this protocol.
- Clinical practice related to H1N1 influenza is being updated regularly in response to information released by the Emergency Coordination Centre and the Acting Director of Health.
- The first call was made to the Tasmanian Ambulance Service was made at 2.09am with a second call being made at 2.38am. The ambulance did not arrive until 46 minutes after the first call was made.
- Dr Lawrence was asked to comment on whether the time taken for the ambulance to attend may have impacted on Ms W’s prospect for surviving. Dr Lawrence stated that, ‘It is extremely difficult to tell whether the delay in the ambulance attendance contributed to Ms W’s death. Examination of the lungs under the microscope show very badly damaged lungs. From my reading on swine flu, this pathology causes a very abrupt deterioration which is difficult to treat. It is possible that, even if the ambulance attended at the time of the first call, the lung damage was so advanced that effective oxygenation by intubation and ventilation may not have been successful. However, in a very sick child it is reasonable to expect prompt resuscitation, and prompt resuscitation was the best chance for survival’.
The Tasmanian Ambulance Service (TAS) provides emergency pre hospital care and transport services throughout a network of 50 stations State-wide. All requests for service are made through a central communications area situated in Hobart. The communications centre has four work stations. Each of the 3 geographical regions has a separate dedicated communications officer. A senior communications officer provides support from the fourth station to all regions on day shift only. Each communications officer receives calls, prioritises cases and dispatches ambulances on the calls. Communications officers also have the capacity to assist other regions when they have an influx of calls to ensure that calls are not left unanswered.
- All requests for service received by TAS are prioritised utilising the Medical Priority Dispatch System AMPDS Version 9. This is an internationally recognised dispatch system to determine the urgency and level of response required to safely manage the incident.
A Serious Incident investigation was conducted by Mr Peter Hamilton of the National Academies of Emergency Dispatch in respect to the Tasmanian Ambulance Service’s response to the 000 call’s made by the family of Ms W. The report identified the following issue:
The Emergency Management Department (EMD) has failed to follow up on the presenting patient’s condition which included a change in both the normal conscious state and breathing pattern. The basic principles of dispatch need to be reinforced here – the previous diagnosis of the patient (flu disease) and the fact that the hospital sent her home some hours/days ago may have nothing to do with the patient’s current condition. To err on the side of caution, the EMD should always continue interrogation of the caller regarding the patient’s condition now. Whilst it is possible that the patient is suffering from a relatively minor ailment having been already medically assessed, there is no guarantee that the patient’s condition hasn’t deteriorated in the time since being looked at by the doctor.
There was no attempt to ask any clinical questions about the patient’s condition. At the very least, protocol 26 (sick person) is an appropriate starting point when there are no clear symptoms that fall into any particular category.
o It appears that the EMD decided that the patient has a non-time critical condition without asking any key questions or clarification of the patient’s level of consciousness and breathing. This person may have had flu – but, like any patient with respiratory difficulty (identified during the second phone call), the protocol needs to be followed.
The customer service component of the audit also identifies some prohibited behaviour – the phases ‘not much the hospital can do’, ‘not much the ambulance can do’, and ‘there is going to be a delay because the Devonport unit is out’ does not provide any positive reassurance for the caller or the patient’.
In summary, it appears that the EMD had made a telephone diagnosis of a non-critical nature, based on the information provided by the caller without clarifying the current condition of the patient, or following the basic requirements of the protocol system.
The following recommendations followed the completion of the Serious Incident investigation.
All communications staff should be required to obtain and maintain currency in AMPDS or other dispatch program’s accreditation.
AMPDS to be utilised as a mandatory patient prioritisation system for all ambulance response service. Variation of an AMPDS classification should only be made by an approved clinician.
Operational policies should be updated to ensure that clear direction is provided to staff in prioritisation of cases.
Appoint a Quality Support Coordinator to undertake audit, training and mentoring for communications staff in the use of AMPDS.
TAS should review it’s current case classification and consideration be given to aligning the classification to the 4 classifications set by AMPDS.
TAS should adopt an accredited communications officer training program. This program should be offered to all current communications staff and become a mandatory requirement for all new staff.
The position of senior communications officer needs to be reviewed to ensure that the role provides support, coaching and mentoring to all communications staff.
All staff, when acting in senior roles should be given sufficient orientation and training to enable them to undertake all aspects of that role.
I understand that TAS is currently taking steps to implement the recommendations outlined in the report of Mr Hamilton. I encourage them to continue with that process.
I note that Mrs W was provided advice by Dr Lurie to have Ms W reviewed by her general practitioner the following day. However, I note that Mrs W indicates that she understood that the Mersey Community Hospital or their representative was going to make these arrangements. For whatever reason, Ms W was not reviewed by a medical practitioner until she was taken to the Mersey Community Hospital by ambulance on the 23 July, 2009.
The circumstances surrounding the death of Ms W were the subject of an investigation by Tasmania Police. The death was not considered suspicious.
Comments & Recommendations:
I am satisfied on the evidence that the decision to discharge Ms W from the Mersey Community Hospital was a clinical decision and not an unreasonable one based on Ms W’s symptoms and the negative result of the H1N1 influenza 09 test. The decision by Dr Lurie not to treat Ms W with Tamiflu albeit clinically correct at the time, may have ultimately reduced her prospects of recovering from this serious illness.
I find that in this case the response by the Tasmanian Ambulance Service was not in accord with acceptable guidelines. I am satisified that the Serious Incident investigation carried out by Mr Hamilton of the National Academies of Emergency Dispatch has adequately addressed the identifiable shortcomings in this response. I accept and adopt the recommendations which flowed from this investigation and urge the prompt implementation of all of those recommendations.
I find on the evidence that Ms W died of H1N1 09 viral pneumonia (swine flu).
I conclude by conveying my sincere condolences to Ms W’s family.
This matter is now concluded
DATED : Friday,11 February 2011 at Launceston in Tasmania.