Record of Investigation Into Death (Without Public Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Stephen Raymond Carey, Coroner, having investigated the death of

Christine Julie SMITH



a) The identity of the deceased is Christine Julie Smith ("Mrs Smith") who died at 0545 hours on 28 April 2010 at the Royal Hobart Hospital.

b) Mrs Smith was born on 31 July 1956 and was aged 53 years.

c) Mrs Smith was divorced.

d) Mrs Smith died as a result of hypoxic brain injury complicating a post seizure cardiac arrest.

Circumstances Surrounding the Death:

The children of Mrs Smith report that she had for as long as 30 year suffered with mental disorders which appeared as depression, anxiety and panic attacks. It was these mental health issues which led to her becoming reclusive and in more recent years reliant upon her children for accommodation. Her children report her use of various medications in respect of these mental health issues over the years but her overuse and inappropriate use of some medication in more recent years had become problematic both to their mother and to themselves in their attempts to care for her and maintain her health. A summary of her most recent mental health assessment was provided in a report from Dr David Lang, Senior Psychiatry Registrar to her treating general practitioner dated 18 December 2007. He states:

"I reviewed Christine in clinic today. She presented with longstanding problems of multiple anxieties and panic attacks. She also had a diagnosis of "psychosis and schizophrenia" She describes occasional panic attacks which limit her being able to go places, for fear of further panic attacks."

He goes on to say:

"I see no indication whatsoever that she suffers from a psychotic disorder. I think what may have been confused with psychosis in the past is probably related to low intellectual functioning. Psychometry performed in 2003 indicates she has a full scale IQ of 65. I would also recommend rationalising the benzodiazepines that she is currently taking."

A treating general practitioner, Dr Christine Funnell, provided a report dated 30 April 2010. She states:

"I have looked after Chris for many years having taken over her care after Dr Pitney left the surgery years ago. Dr Krishna was seeing her for a while but I took over again in an attempt to set some limits as she was ringing frequently and being very uncooperative with appointments. I did not like prescribing Kalma for her as I felt these were particularly open to abuse so bargained 3 Serepax a day and only 2 Kalma with a view to having a regular weekly appointment to try and improve compliance. She did attend more reliably but it was still difficult as she had moved in with her daughter at Kingston. I offered to facilitate her transfer of care to a doctor in the area but she chose to continue here. Over the last 3-4 months it became increasingly difficult to keep her at 2 Kalma a day as she repeatedly asked for scripts early and was obviously taking at least 3 a day despite her denials. After several warnings I finally refused to repeat her script early despite the fact that she said she had none at home. Over the next week she presented to the DEM at RHH on about 3 occasions seeking sedatives."

Dr Funnell then explains her endeavours to cease the use of certain medication and attempt to control withdrawal symptoms that may then have occurred. Her endeavours in this regard are outlined in a further letter provided dated 29 June 2010. It was noted that the predominant diagnosis throughout her attendance at the medical practice was one of panic disorder with chronic anxiety in the background of a person with low intelligence. She had been referred to the Eastern District Mental Health Service but contact had been terminated by them because of Mrs Smith's poor compliance and attendance. It was felt that further referral for psychiatric input would not have been useful because of these compliance issues. Dr Funnell comments that:

"She had been taking various sedative medications for many years and had a tendency to use more than was prescribed. This was especially a problem with the Xanaz which is a very fast acting sedative. She would tend to take this whenever she was upset and I had been trying to limit her access to this over the weeks before she died. She also had regular doses of serepax which is another sedative. I saw her a few days before she died when she requested referral to the Drug and Alcohol Service to be detoxed from the sedatives. In the interim I ceased the Xanax and serepax and put her on 2 valium a day. This is a longer acting sedative which is often used as part of withdrawal programs."

Ms Pamela Ford, a daughter of Mrs Smith, reports that her mother had been living with her since June/July 2009. She opined, no doubt based upon her observation of her mother's drug use, that her mother was suffering from prescription drug abuse. She said she attempted, by talking to her mother, to have her reduce her medication intake or try alternate therapies both of which were refused. Ms Ford notes that her mother:

"...was very rarely happy, she was a troubled soul. This began to frustrate me. She used to ring me up at work and demand that I pick up tablets from the chemist or ask me while I was at home with her. I would go to the chemist and they'd state to me that she wasn't due for any more medication for approximately 14 days or something which is (sic) apparent of her drug abuse problems."

Ms Ford explained that her relationship with her mother became a little strained due to these issues revolving around her drug reliance/abuse. She therefore made arrangements with her brother Matthew for her mother to live with him as she could not deal with the issues any more. Mr Matthew Smith confirms that at some time on or about 12-14 April 2010 his mother moved into his house. He confirms his mother's drug problems and became aware that his mother was "doctor shopping" in an endeavour to obtain more medication than what was prescribed for her. In particular she seemed addicted to the medication Kalma as he was aware his mother was ringing up doctors and pharmacies demanding more of that drug. He concluded that:

"She definitely had a reliance on the tablets and when they were not available to her she would have withdrawal symptoms - causing her to become forgetful, disorientated, short term memory loss, unbalanced and dizzy."

He then provided detail of taking his mother to the Department of Emergency Medicine at the Royal Hobart Hospital on Saturday 17 April 2010 as she was complaining of high blood pressure, headaches, dizziness, increased heartbeat and generally feeling unwell. On Sunday 18 April she was discharged and came back to their house. Upon her discharge she was, he believes, provided with 2 days' worth of medication and he believes that she took all of the medication to "make up" for not having had any recently. He then notes that he believed that on Tuesday 20 April his mother's general practitioner removed her medications and only prescribed valium in return. He says his mother was not impressed and kept pestering him and his partner as well as doctors and pharmacies for more. In the early hours of Wednesday 21 April 2010 at approximately 0430 hours his mother came into their bedroom screaming "I can't breathe, I can't breathe". He believed she was having an anxiety attack. An ambulance arrived and she was conveyed to the Royal Hobart Hospital, being released later that morning. He noted during that day that she was vomiting constantly and he believed that this was due to withdrawal of medication. Later that day it became obvious that she was having difficulty controlling her bodily functions. Due to these issues and her continuing vomiting an ambulance was called at 1630 hours and transported his mother to the Royal Hobart Hospital. At 1900 hours Mr Smith received a telephone call from his mother to come and collect him as she refused to be seen and wished to leave the hospital. He noted upon her return that she appeared increasingly disorientated and dizzy and almost appeared to be intoxicated. However she showered and changed and went to bed but she was "making weird noises".

The next morning when Mr Smith and his partner awoke they determined Mrs Smith was not at home and assumed she had gone to hospital as there was an ambulance vomit bag and other material in the house. They attended the hospital between 9.00 and 10.00 am on the Thursday and were made aware that Mrs Smith had been admitted to the Intensive Care Unit.

Information was sought from the Royal Hobart Hospital regarding the care of Mrs Smith when she attended the Emergency Department of the hospital in the days leading up to her death. Detailed reports were received from Dr Dean Powell, Acting Director of Emergency Department dated 13 December 2010 and Professor Anthony Bell, Chief Medical Officer dated 21 July 2011.

Dr Powell notes that Mrs Smith presented to the Emergency Department on 17 April at 2103 hours requesting a script for Alprazolam and Oxazapam (both Benzodiazepines) as she had run out of that medication. She was assessed as non urgent but at 00.15 hours on 18 April it was noted by a triage nurse that Mrs Smith was now requested admission to the Psychiatry Ward. She was noted as "dizzy, anxious and hallucinating". Mrs Smith was seen at 0334 hours by the overnight resident who made an extensive assessment. She claimed to have run out of her Benzodiazepines some five days earlier. She felt shaky and sweaty, had hot flushes, diarrhoea and palpitations and at times had visual hallucinations. She was noted to have an elevated pulse and blood pressure, she had occasional thoughts of suicide but no plan in that regard and it was felt her presentation was consistent with Benzodiazepine withdrawal. Blood tests were conducted and they showed a few anomalies which were all felt to represent a response to drug withdrawal.

She remained in the Emergency Department overnight and was referred to the Psychiatry Service in the morning for assessment and opinion. From that assessment she was given 2 x 2 mg doses of Alprazolam and advised to see her GP for ongoing doses. She left the hospital at 1650 hours.

She was noted as returning the same evening at 2001 hours and she was noted to have suffered a brief self limiting seizure. She was reassessed by a different overnight resident particularly with respect to the seizure. Apparently Mrs Smith had taken all 4 mgs of the Alprazolam dispensed from Royal Hobart Hospital 10 mins prior to this seizure. She again remained overnight in the Emergency Department and underwent a head CT scan in the morning. During the night she was given two doses of 20 mg Diazapam to counter withdrawal symptoms. Blood testing was repeated and had changed little and her CT scan was essentially normal.

Mrs Smith presented again on 19 April at 2213 hours. At this time she reported problems breathing and she complained of difficulty swallowing. The triage nurse noted she was very vocal in the waiting room, talking in full sentences and without any apparent respiratory or swallowing difficulty. On this presentation her son called to request that she be admitted to the Psychiatry Ward as the family was having difficulty with her and that she "needed to go into detox". Over the next two hours she was in and out of the waiting room for cigarettes, then at 0035 hours it was noted she was not in the waiting room and did not return. She had not been medically assessed on that occasion.

She returned to the Royal Hobart Hospital on 21 April at 0457 hours. She had increasing agitation, anxiety, insomnia, occasional palpitations and some nausea, vomiting and diarrhoea. It was noted that her son was now managing her medications, she felt depressed but not suicidal, her vital signs were assessed as normal. She was thereupon discharged home but was offered a referral to a social worker. She left at 0715 hours. She then returned to the hospital at 1741 hours with her son who was concerned about an episode of urinary incontinence. Mrs Smith refused to stay to be seen by a doctor, however the psychiatry emergency nurse was able to determine that she had no thoughts of self harm and that she had a case worker with the Community Mental Health team, this team were notified to try and contact her the next day.

Finally Mrs Smith returned to the Royal Hobart Hospital at 0026 hours on 22 April. She was once again triaged as a non-urgent patient although she was complaining of shortness of breath and withdrawals, she was comfortably, talking in full sentences and had normal vital signs. At 0440 hours she had calmed a great deal, had taken two of her Metoprolol tablets and was noted to be drinking a good deal from her water bottle which she would refill in the waiting room. At 0445 hours she was shown through to a seclusion room with a mattress and recorded as stating she "felt fine". At 0545 she was discovered in that room lying on her back, pulseless and in respiratory arrest. Full resuscitation was commenced with CPR, intubation, atropine and adrenalin dosing. Review of the close circuit TV of the cubicle revealed her apparently having a generalised seizure at approximately 5.28 hours.

Blood tests taken shortly after Mrs Smith's collapse showed a below normal concentration of sodium, potassium, chloride, bicarbonate and urea, and a higher than normal white blood cell count. Mrs Smith's condition was stabilised and she was admitted to the Intensive Care Unit at 9.00 am where she remained critically ill. She was treated for her electrolyte imbalances, and emerging chest infection (most likely aspiration-related) and a hypoxic brain injury. Neurological assessment including MRI and EEG testing, along with her clinical status, revealed Mrs Smith had suffered a severe, irreversible hypoxic brain injury as a result of her in-hospital cardiac arrest and unknown "down time". In consultation with her family active treatment was withdrawn from Mrs Smith on 27 April 2010 and she died on 28 April 2010.

The death of Mrs Smith has been the subject of a detailed investigation with particular emphasis on her multiple visits to the Emergency Department of the Royal Hobart Hospital in the days leading up to her death and also the decision to place her unattended in the seclusion room on her last visit.

Comments and Recommendations:

The issues and concerns in this matter were articulated in the report from Dr Dean Powell, Acting Director of Emergency Department, Royal Hobart Hospital in his advice of 13 December 2010 in which he states:

"There are several issues of concern in this case, namely the decision to manage Mrs Smith in a seclusion room, the lack of recognition of her polydipsia, the apparent rapid fall in her sodium levels over such a short time and the failure of the system to address her issues sufficiently so she did not need to continue presenting to the Emergency Department."

I will deal firstly with the issue as to the failure to diagnose the condition of polydipsia which it is thought was at least contributing to the physical and psychological complaints suffered by Mrs Smith that, at least on the last occasion, contributed to her need to attend at the Emergency Department. A patient with psychogenic polydipsia has an urge to drink water (thirst) not related to the need for water based upon the water content of the body. As the person drinks large volumes of water the serum chemistry is diluted and the serum sodium falls. This can lead to hyponatremia and if this condition develops rapidly (within 48 hours) has serious sequelae, including confusion, hallucinations, seizures, coma, and respiratory arrest leading to death. Professor Anthony Bell, Chief Medical Officer Royal Hobart Hospital, in his report of 21 July 2011 notes the blood test results taken after Mrs Smith had suffered her cardiac arrest. These results with the significantly lowered concentration of, in particular, sodium he believes to be typical of the syndrome of inappropriate anti-diuretic hormone release (SIADH). In such circumstances the person has released ADH for reasons not related to the control of total body water. This leads to a dramatic fall in the level of serum sodium. He goes on to explain that the causes of SIADH are multiple but he believed in this particular case the most likely are drug induced, related to seizure activity, related to drug withdrawal syndrome, or related to an inter-current infection. Professor Bell then notes that the triage nurse at 00.26 hours on 22 April 2010 noted that Mrs Smith was agitated, fidgety, confused, drinking water and unsteady. Mrs Smith had reported two days of vomiting and diarrhoea. He states that this description fits the clinical syndrome of SIADH but points out that it is also similar to the description of the drug withdrawal syndrome (hallucinations, erratic thoughts, panic symptoms) and to pick the difference clinically would be difficult if not impossible. He describes that usually the diagnosis of SIADH is made by measuring serum sodium levels in patients who present with confusion and in severe cases, seizures. He concluded that the onset of SIADH was clinically difficult if not impossible to detect on Mrs Smith's final presentation without reference to blood tests. He also points out that previous blood tests had been within the normal range. Dr Powell comments that in this case the profound and rapid drop in Mrs Smith's sodium level was surprising. In particular, she went from a sodium level of 130 mmol/L on 19 April 2010 to a reading of 101 at 06.14 hours on 22 April 2010 which he described as extraordinary.

I am satisfied based upon the medical opinions provided that in the circumstances of this case no criticism can be made of the attending medical staff in failing to diagnose psychogenic polydipsia together with SIADH given that both diagnoses are usually made as a matter of exclusion and that the presenting symptoms of Mrs Smith were also consistent with her drug withdrawal and abuse issues, especially in the setting of known mental illness. However I do comment that given the repeated presentations with the clinical features consistent with hyponatremia the index of clinical suspicion should have been raised by those dealing with her in the Emergency Department, and perhaps too much weight was given to her drug abuse/withdrawal issues.

It is also explained by Dr Dean Powell that in August 2010 a new role of Psychiatric Emergency Nurse (PEN) was created within the Emergency Department. Persons will be chosen to fill these positions having dual general and psychiatric training and whose role it will be to initially review mental health patients on arrival into a cubicle (usually the secure rooms), make an assessment of their needs and safety and begin to provide these. Their focus will be upon the mental health of patients. It is intended that these nurses will have sufficient experience and seniority to effectively be the primary carer for these patients whilst they are in the Emergency Department and they will have the authority to refer directly to in-patient services if required. This initiative is to be commended and hopefully funding for these positions will be maintained notwithstanding the present financial issues impacting upon the Royal Hobart Hospital.

The further matter is the apparent inappropriate demand and expectation placed upon the Emergency Department staff to attend to Mrs Smith's many and varied problems that transcended emergency physical or mental care. Dr Powell comments in this regard;

"Finally there is the issue that the system was unable to adequately recognise and treat the ongoing mental health issues for this woman and her family such that they felt that she did not need to continue to present to the Emergency Department. In truth, only the consequence of her last presentation was truly an emergency, and all her other issues could have been addressed in the community if there were adequate services in place. General practitioners are usually left to try to co-ordinate care recommended from other services and in this case that would include drug withdrawal, detoxification, anxiety disorder and social issues. Unfortunately, specialist services tend to concentrate on their own area and do not always integrate the whole. In addition it can take some time from referral to see such services, consequently some patients present to the Emergency Department. Many of these problems are outside our scope or expertise."

This is a valid comment and unfortunately many people turn to the Emergency Departments of our General Hospitals as the only readily available service. This in turn compounds the difficulties of staff within these Emergency Departments to deal with their casualty and general workload.

Dr Powell goes on to state:

"When instituting the role of the Psychiatric Emergency Nurse it was recognised that here has been a gap in support for mental health patients in the first few days after a visit to the Emergency Department. In an attempt to fill this, an Emergency Community Assessment Team has been formed with the Mental Health Services. This team will review all people discharged from the Emergency Department with a mental illness within 24 hours of discharge. This review occurs by phone or at times by a home visit. Since this service started, the number of people able to be safely discharged to their own homes has increased."

I once again compliment those involved for establishing this service. It is possible when considering this matter in retrospect to suggest that had Mrs Smith been provided with appropriate mental health support at the commencement of her acute period of distress on or about 17 April 2010 she may well have received the level of support that she required in respect of the challenges imposed by her addiction to prescription medication. I do not however criticise the treating general practitioner who commenced a process with Mrs Smith to withdraw her from medication to which she was addicted and which was causing her significant ill effects, both physically and mentally. However there was apparently an assumption that ongoing support during this process would be provided by Community Mental Health Services. This did not occur due to the refusal of Mrs Smith to be compliant. Given the significant issue we have in our community of addiction to prescription medication, it is perhaps time to look to long term, controlled and co-ordinated withdrawal programs rather than leaving the burden on the general practitioner, our public hospitals and more importantly the families.

Finally I do not consider, based on the information provided, that the condition of Mrs Smith as reasonably assessed at the time made it inappropriate to place her in a seclusion room to rest upon her last visit to the Emergency Department.

Before concluding I would like to convey my sincere condolences to the family of Mrs Smith.

DATED this 12 day of January 2012


Stephen Carey