RECORD OF INVESTIGATION INTO DEATH (WITHOUT INQUEST)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Robert Pearce, Coroner, having investigated the death of
Melanie Patricia BOURKE
WITHOUT HOLDING AN INQUEST
FIND:
(a) Melanie Patricia Bourke died on or about 7 December 2010 at Mersey Community Hospital, Latrobe aged 25 years;
(b) Ms Bourke was born in Launceston on 4 June 1985 and at the time of her death was single and a disability pensioner;
(c) Ms Bourke died as a result of aspiration pneumonia and pyelonephritis;
(d) at the time of her death she was being treated by a medical practitioner.
(e) no other person contributed to the cause of Ms Bourke’s death.
Background and investigation
1. Melanie Bourke died on 7 December 2010 aged 25. Prior to her death she lived in Devonport. She had poor health. She had a long history of chronic medical conditions and an extensive medical history. She was an insulin dependent diabetic. Her health was complicated by her non-compliance with management of her diabetes and general lack of self-care. She had been admitted to hospital more than 100 times in the previous seven years, mostly because of her diabetes. Both the North West Regional Health Service and Tasmanian Ambulance Service had a specific management plan for use when Melanie required treatment. One aspect of her condition when she was unwell was extreme agitation and physical resistance to paramedic and medical intervention and so sedation was integral to the management plan.
2. On 4 December 2010 Melanie had a fall at home. On 5 December 2010 her mother, Denise Bourke, called for an ambulance. Melanie was taken to the Mersey Community Hospital at Latrobe. On 7 December 2010 she suffered two cardiac arrests and she died at about 3.15pm.
3. The coronial investigation of Melanie Bourke’s death has included, amongst other things:
(a) a post mortem examination;
(b) review of the records of the Mersey Community Hospital ("the MCH") and the Tasmanian Ambulance Service;
(c) a comprehensive report from Professor Michael Buist, the Clinical Director of Intensive Care at the Mersey Community Hospital;
(d) a review of the post mortem examination by the Director of Statewide Forensic Medical Services, Dr Christopher Lawrence;
(e) a toxicology report from Forensic Science Service Tasmania;
(f) advice in conference from a senior nurse investigator engaged by the Coronial Division and Dr Lawrence.
4. In the course of the investigation Melanie Bourke’s mother, Denise Bourke, expressed some concern that Melanie’s death was contributed to by the medication administered to her on and following 5 December 2011. The investigation has been conducted with that expression of concern in mind.
5. The starting point is to determine the cause of Melanie’s death. I am satisfied from the post mortem examination and Dr Lawrence’s opinion about the results of that examination that the cause of her death was aspiration pneumonia and pyelonephritis. Aspiration pneumonia is inflammation of the lungs and airways leading to the lungs from breathing in foreign material, for example food or vomit. This may lead to swelling and inflammation in the lung or a lung infection (pneumonia). Pyelonephritis is an infection of the kidneys. In Dr Lawrence’s opinion, which I accept, the aspiration pneumonia was well established at the time of death and was probably highly significant in the cause of death. Her kidneys were considerably damaged and she had deteriorating renal function. The effect of the sepsis, whether arising from the pneumonia or the kidney infection or both, was a series of physical consequences, not all of which can be precisely identified, but ultimately leading to heart failure.
Circumstances leading to Ms Bourke’s death
6. The ambulance arrived at Ms Bourke’s home at about 2.15pm on 5 December 2010. Presumably because of the known difficulty in attending to Melanie’s care a senior paramedic, Andrew Muir, was also called to assist. Melanie was in pain, had nausea and had vomited food. The initial assessment was of hyperglycaemia. She complained of back pain. She was monitored, including with a cardiac monitor and given oxygen therapy and insulin. The management plan prepared by the Tasmanian Ambulance Service Medical Officer in conjunction with the MCH Director of Emergency Medicine was implemented. To inhibit her agitation and allow safe transport to hospital she was given 5mg of midazolam to sedate her. However, she remained agitated and non-compliant. She was administered 100mg of Ketamine. The management plan provided for administration of 150mg of Ketamine but Mr Muir decided on a lower dose. That dose proved to provide effective sedation and she was safely taken to the MCH.
7. She arrived at the hospital at 3.12pm. In the Department of Emergency Medicine 200mg of Ketamine was administered intramuscularly at 3.30pm and a further 100mg of Ketamine at 4.05pm. She was assessed and examined and given other general treatment and transferred to the High Dependency Unit at 6.10pm where further assessments and monitoring were undertaken. Her left lower leg was in a plaster cast from an earlier fracture. She had a chest x-ray that showed no abnormality.
8. Ms Bourke was assessed by the locum consultant physician the following morning, 6 December 2010, at 8.55am. She continued to complain of back pain. Plain x-rays revealed no fractures.
9. During the morning of 6 December the Director of Medicine instructed that, in accordance with the patient management plan, Melanie should be transferred to the North West Regional Hospital in Burnie (“the NWRH”). However advice was received from the NWRH that no beds were available and so she was kept at MCH.
10. During 6 and 7 December Melanie continued to be agitated and complain of back pain. Her condition deteriorated. She was not eating and required ongoing sedation and analgesia as well as an insulin infusion.
11. Just after 10.00am on 7 December Melanie was noted to have a profoundly slow heart rate. She was pale and unresponsive. Resuscitation attempts were urgently commenced. Further measures were taken to treat her and stabilise her condition. A chest x-ray disclosed possible aspiration. An echocardiogram also disclosed a dilated right ventricle. Dr Buist attended at 11.50am and diagnosed pulmonary embolus. Arrangements were made for Melanie to be transferred to the Royal Hobart Hospital for surgery. However later in the afternoon Melanie suffered a further cardiac arrest and could not be resuscitated. She died at 3.15pm.
Matters arising from these circumstances
12. Melanie’s mother has expressed concern about the circumstances leading up to her daughter’s death. A particular matter she raised was a comment made by the paramedic, Mr Muir, about the level of ketamine described by the management plan as to be administered to Melanie, that it was “enough to kill a horse”. Mrs Bourke’s concern is understandable but, as a result of the investigation, I am satisfied that the level of medication administered to Melanie was not excessive. Mr Muir’s remark was made in passing and colloquially and intended only to indicate that the same result could be achieved with a lower dose. The toxicology report lists medications present at therapeutic quantities only. Her medication did not contribute to her death except that her sedation may have increased the risk of aspiration.
13. Other matters have emerged during the investigation. It is now acknowledged that Melanie should have been transferred earlier to the NWRH in accordance with the management plan. Professor Buist also acknowledges that there was an insufficient assessment at a sufficiently senior level of Melanie’s deteriorating condition and the origin of her back pain.
14. Even so, it must be acknowledged that Melanie was a difficult patient, she presented with atypical symptoms and, even with the benefit of the post mortem findings, it is difficult to unequivocally identify the cause of all of her symptoms and signs and to diagnose her condition. The post mortem findings are difficult to reconcile with Melanie’s signs during her admission. The attribution of an orthopaedic cause to the back pain, given her history, was understandable although an alternative cause was not considered and it was later revealed that it is likely that the back pain was due to the infection in her kidneys. The diagnosis of pulmonary embolus, when it was made, was a reasonable one even though the post mortem examination casts doubt on it. Professor Buist points out that the finding of a grossly dilated right ventricle suggests least transient obstruction. I accept the advice of Professor Buist that even if Melanie had been transferred to the NWRH it is unlikely that her treatment would have altered.
15. I regard it as likely that the infections were present prior to Melanie’s admission. However even if they had been earlier diagnosed and aggressively treated, Melanie was so unwell that the infections placed her at significant risk, whatever course was taken. The deterioration of her condition and the cardiac arrests are still likely to have occurred.
Comments & recommendations
16. By s28 of the Coroners Act a coroner investigating a death is required to find, if possible, when and where the person died, how the death occurred, the cause of death and to identify any person who contributed to the cause of death. The primary focus of an investigation is to seek out and record the facts concerning the death of a person. It is a fact finding exercise of an inquisitorial nature. The facts which are relevant are those which may enable findings about the matters the Act requires the coroner to, if possible, determine. However it is proper that an investigation should identify not only the direct means or mechanism of death but also the circumstances attending the death. It is not the function of an inquest to attribute any moral or legal responsibility or liability for a death or to hint at blame. It is not a means of apportioning guilt. A coroner is to determine facts. The facts, once determined, will speak for themselves and it is for others to, if necessary, draw legal conclusions.
17. I have decided not to hold in inquest into Ms Bourke’s death. The investigation has sufficiently disclosed the identity of the deceased person, the time, place, the relevant circumstances concerning her death and the particulars needed to register her death under the Births, Deaths and Marriages Registration Act. I am satisfied that no other person contributed to Ms Bourke’s death. I do not consider that an inquest is likely to elicit any further information concerning the issues that I am required to determine.
18. The investigation has also resulted in steps being taken at the Mersey Community Hospital to review and address some of the issues that arose in the course of Melanie’s care. They relate to record keeping and monitoring of deteriorating patients. This challenging case serves as a reminder to clinicians of the need for close vigilance when caring for sedated patients with heightened risk of aspiration, particularly if diabetic and at risk of becoming critically ill.
I convey my sincere condolences to Ms Bourke’s family.
DATED: 19 September 2012 at Launceston in Tasmania
Robert Pearce
CORONER