Inquest into the death of Joanne Craig
[2019] NTLC 26
•20 September 2019
CITATION: Inquest into the death of Joanne Craig
[2019] NTLC 026
TITLE OF COURT: Coroners Court JURISDICTION: Darwin FILE NO: D0013/2018 DELIVERED ON: 20 September 2019 DELIVERED AT: Darwin HEARING DATE(s): 27, 28 August 2019 FINDING OF: Judge Greg Cavanagh CATCHWORDS: Failure of primary care providers to
offer vaccination (Pnemovax23),
Failure by hospital to identify sepsis,
Failure to identify septic shock,
antibiotics commenced too lateREPRESENTATION: Counsel Assisting: Kelvin Currie Counsel for Top End Health Service Stephanie Williams Counsel for Dr Brummit Marie Savvas Judgment category classification: B Judgement ID number: [2019] NTLC 026
Number of paragraphs: 70 Number of pages: 26
IN THE CORONERS COURT
AT DARWIN IN THE NORTHERN
TERRITORY OF AUSTRALIA
No. D0013/2018
In the matter of an Inquest into the death of
JOANNE CRAIG
ON 24 JANUARY 2018
AT KATHERINE DISTRICT HOSPTIAL
FINDINGS
Judge Greg Cavanagh
Introduction
The Deceased, Joanne Craig, was a 57 year old woman of Aboriginal
descent from the Wurrumunga clan group. She was born 5 October 1960 in
Tennant Creek to Peggy Corp and Noel Corp. She had five brothers and
sisters. On 20 October 1984, at the age of 24 years, she married Steven
Craig. They had four children: Daniel, Michael, Steven Jr and Lindsie. They
had 11 grand-children. They took on many other children also after the
deaths of two family members and two friends.
In 1994 Joanne and Steven took over management of Mistake Creek Station,
a 4000km[2] cattle station located about 630km southwest of Katherine.
Joanne was an equal partner in the innovations and the running of the
station.
Through their hard work they transformed the station into a modern,
innovative and successful station. They quadrupled the cattle numbers. They
developed the infrastructure and the business management. They developedthe capacity of their staff and managers. They modernised the processes and
procedures. They ran low-stress stock handling and horsemanship skills
courses and became an accredited training facility. They conducted Rural
Operations courses for the Education Department.
Students from schools as far afield as Centralian Senior College in Alice
Springs, Tennant Creek High School and Taminmin College in Humpty Doo
have participated in 10-day courses at the Station. Joanne and Steven
became involved in the Australian Rural Leadership Program. Employees
involved can complete certificates II, III and IV in Beef Management.
Joanne was tireless. Apart from the station business she was passionate
about her family. She was the family organiser and connector. She loved her
dogs and horses, she was a photographer and an avid sports person.
Joanne looked after her health. She didn’t smoke and didn’t drink and saw
the health professionals on a regular basis. Records indicate that she
attended the doctors at Wurli-Wurlinjang Health Service in Katherine
between 2009 and November 2017. She also attended on Kintore Clinic in
Katherine (later taken over by Gorge Health Services) between at least 2010
and September 2016. There are also records from the Central Clinic Alice
Springs that show four attendances on doctors from 2004 to 11 January
2018.
On Tuesday 5 December 2017 Joanne went to the Central Clinic Alice
Springs for a check-up prior to flying to the United States of America for
two weeks with her daughter. She left for the USA two days later on 7
December 2017. She returned on 23 December 2017.
On 23 January 2018 Joanne and Steven were in Katherine. While having
dinner at the Katherine Golf Club, Joanne complained of feeling cold and
feverish. They returned home at about 9.00pm. She took Panadol and wentto bed.
The following morning she was still unwell and Steven drove her to the
Emergency Department of the Katherine District Hospital. She was triaged
at 9.12am. Her presenting symptoms were recorded by the triage nurse as:
“Vomiting/nausea. One day (1/7) fevers, vomiting x 4 this morning,
global aching. Tolerating fluid intake, ongoing productive cough
since late December”.
Her vital signs were recorded as:
“Temp 39.9; pulse 126/min; respiratory rate 18/min; BP 116/73
mmHg; oxygen saturation 98% .”
Venous blood gas (VBG) results showed mildly reduced potassium (3.0
mmol/L) and elevated lactate (2.3 mmol/L). The working diagnosis was a
likely viral illness with no clear source of infection. The plan was for
further observations and investigations.
Her condition deteriorated throughout the day. She went into cardiac arrest
at 8.42pm. She was declared life extinct at 9.25pm.
Her blood cultures grew streptococcus pneumoniae. In the opinion of the
Forensic Pathologist, Dr Marianne Tiemensma, she died due to multiple
organ failure caused by sepsis that was due to streptococcus pneumoniae
infection.
It was apparent that when she arrived at Katherine Hospital and was triaged
at 9.12am she was suffering from sepsis. The only way to treat sepsis is the
administration of broad spectrum intravenous antibiotics at an early stage.
According to one expert she should have been provided broad spectrum
antibiotics by midday at the latest. If that had happened she is likely to have
survived. According to another expert she should have had antibiotics
shortly after 3.30pm. If that had happened she may well have survived.However withholding antibiotics until 7.40pm gave her no chance for survival.
The bacteria
Streptococcus pneumoniae is a gram positive bacteria. It is an encapsulated
bacteria that (in simple terms) makes it more difficult for the immune
system to combat. It is present as part of the normal bacterial flora in the
nose and throat of up to 10% of adults and up to 40% of children.[1]
The danger
The bacteria can cause septicaemia, an infection of the blood stream. An
initial source of infection is present in less than 50% of cases.2 As indicated
by Dr Raftos:
“The natural course of bacterial septicaemia includes a prodrome
with symptoms of fever, chills, and muscle and joint aches lasting for
hours to days, followed by a precipitous decline to septic shock,multiple organ failure and death.
Appropriate treatment of bacterial septicaemia includes generic
intravenous antibiotics along with intravenous fluid resuscitation.Any delay in initiating intravenous antibiotic treatment significantly
increases the likelihood of both death and permanent disability.”
The vulnerability
The very young or elderly are more vulnerable. Aboriginal and Torres Strait
Islander people lack immunity to encapsulated bacteria.[3] Streptococcus
pneumoniae is a vaccine preventable disease.
The vaccine
The Australian Immunisation Handbook[4] recommends that all Aboriginal
and Torres Strait Islander adults receive the Pneumovax23 (23vPPV)
vaccination when 50 years of age with a further dose five years later. The
Handbook recommends that the rest of the population receive the
vaccination at 65 years of age.
The statistics
The Centre for Disease Control at the Department of Health (Northern
Territory) provided statistics of the extent of coverage of the vaccination for
Aboriginal and Torres Strait Islanders between the ages of 50 and 60
throughout the Northern Territory. The average coverage across all regions
was 50%.
The Katherine region was the lowest with a coverage of only 38%. Alice
Springs Urban area was highest with a coverage of 72%.
The General Practitioners
After the age of 50, Mrs Craig utilised three General Practices in the
Northern Territory: the Central Clinic in Alice Springs, Kintore
Clinic/Gorge Health Services in Katherine and Wurli -Wurlinjang Health
Service in Katherine.
Central Clinic Alice Springs
Mrs Craig attended the clinic on two occasions. Once on 5 December 2017,
before she went on her trip to the USA and on 11 January 2018 on her
return. On both occasions the consultation was primarily around her blood
pressure. On the first visit it was 180/100 on the right arm and 190/85 on the
left arm. She was prescribed Perindopril Arginine (5mg each morning). On
her return her blood pressure had reduced to 145/84.
Wurli-Wurlinjang Health Service
Mrs Craig attended the Service on a number of occasions in 2009 and 2010
just prior to turning 50. She then attended in 2014 in relation to a cough and
shortness of breath and then in November 2016 primarily in relation to
grieving after the death of her father, skin lesions, cutaneous lupus
erythematosus and blood pressure. She was referred to the Katherine
Hospital to be linked to specialist care and information was released to
Gorge Health to assist with rheumatologist referral. The plan included
returning in the new year for a full skin check.
Mrs Craig had attended on Wurli-Wurlinjang on 6 February 2017 and 6
March 2017. On that last occasion her blood pressure was taken (145/80)
and her cardiac risk assessed (CVS screen - low 9%). Blood was taken for a
full blood test.
On 13 March 2017 she returned to discuss the blood test results. They were
normal. On that occasion she complained of a sore toe. It was thought likely
to be arthritis.
On 24 April 2017 she attended in relation to joint swelling and pain in a
finger and a right eye pterygium that was becoming an issue. She was
referred to an ophthalmologist. That was the last consultation.
My office asked Wurli-Wurlinjang whether it used vaccination schedules
and why it was that Mrs Craig had not received the pneumovax23
vaccination. In a letter dated 23 May 2019 the Health Service stated, in
effect, that there was no vaccination schedule for pneumovax23, that the
eligibility for the vaccination was prompted during an Aboriginal Health
Assessment and that Health Assessments were offered annually to patients
who identified the Service as their primary health clinic. They stated:
“As Mrs Craig did not identify the Service as her primary health
clinic she may not have been offered an Aboriginal Health
Assessment”.
During the course of the inquest the Senior Medical Officer stated:
“It was probably an … oversight that she was not offered an
Aboriginal and Torres Strait Islander health check at that time.”[5]
Kintore Clinic/Gorge Health Services
There were no medical notes available from Kintore Clinic. The Clinic was
closed on 30 November 2015 and from that date the General Practice
operating from the Clinic site was Gorge Health Services. Dr David
Brummitt operated Kintore Clinic and works for Gorge Health Services. He
said he could not find Mrs Craig’s medical notes from her consultations with
Kintore Clinic.
The medical notes from Gorge Health indicated that in 2016 Mrs Craig saw
the doctors at Gorge Health on four occasions. Twice in May, once in June
and the fourth time in September. The consultations were primarily in
relation to ongoing tests for lupus but also included other medical issues and
support during the final weeks of her father’s illness.
My Office requested similar information from Gorge Health Service to that
requested from Wurli-Wurlinjang. The practice manager responded:
“I would like to inform you that on the 28 November 2016 we
received a fax from Wurli-Wurlinjang asking us for a health would have expected them to have conducted an Indigenous health
summary for Ms Craig, as she was now attending their clinic. As she
never attended Gorge Health after that date, it would seem that
actually Wurli-Wurlinjang was her primary health clinic for at least a
year before her death. This is longer than she was a patient at Gorge
Health.
check and immunised as appropriate. They were Ms Craig’s primary
health clinic.”Mrs Craig was not provided the pneumovax23 vaccination or any
information in relation to it by any of the General Practices she attended.
The Hospital Treatment
There were a number of chronologies of the observations and treatment
received by Mrs Craig while in the Katherine Hospital from her arrival on
the morning of 24 January 2018 until her death that same day. For those who
have a keen interest a copy of the timeline in treatment, as provided by
Associate Professor Dr Didier Palmer (with a few alterations), is appended
to these findings.
Mrs Craig was triaged at 9.12am. It was noted that she had vomiting/nausea,
fever for one day, had vomited four times that morning, had global aching,
was tolerating fluid intake and had a cough since the previous month.
Her vital signs included a temperature of 39.9oC, a heartrate of 126 beats per
minute, a respiratory rate 18 breaths per minute, blood pressure of 116/73
mmHg, and oxygen saturation at 98%. The impression of the doctors was
that she was suffering a likely viral illness with no source of infection. They
believed a differential diagnosis to be a bacterial infection (sepsis). It is said
that she was entered on the sepsis recognition pathway. The pathway at that
time was in the following form:
The risk factor of a history of fevers along with her heartrate (126) and
temperature (39.9) fulfilled the blue and yellow zones. The doctor ordered a
venous blood gas (returned a lactate of 2.3 mmol/L), started her on
intravenous fluids and ordered blood tests. The blood test results were
returned at 11.41am. They indicated a raised white blood cell count of 18.7
(normal 4.0 – 11.0) and raised neutrophil count of 14.2 (normal 2.0 – 8.0).
CRP was 26 mg/L (normal less than 5.0).
The interpretation of those results was a point of contention during the
inquest. The expert witness Associate Professor Dr John Raftos considered
that the blood test results were much more indicative of a bacterial infection(sepsis) than a viral infection. He said if it was a virus those markers would
be unlikely to be raised and more likely suppressed. In his opinion at that
point at the latest antibiotics should have been commenced.
He stated in his report:
“The clinical features of Ms Craig’s presentation to the Emergency
Department at Katherine Hospital on 24 January 2018 included:
Australian Aboriginal heritage,
fever: temperature 39.9oC, tachycardia: heartrate 126 beats per minute, aches and pains:
“GLOBAL ACHING,” - triage nurse,
“myalgia” - medical student,
elevated lactate: 2.3 mmol/L (normal 0.5 - 2.0), markedly elevated inflammatory markers, indicating serious bacterial
infection:
White Cell Count 18.7 x 109/L (normal 4.0 - 11.0),
Neutrophil Count 14.2 x 109/L (normal 2.0 - 8.0),Band Forms 3.1 x 109/L (normal 0.0 - 0.5).
The only safe and reasonable medical synthesis of this presentation,
regardless of any clinical guideline, would be that Ms Craig had a
serious bacterial infection, requiring immediate empirical intravenous
antibiotic therapy and management in a closely monitored clinical
environment, either the Emergency Department or an Intensive Care
Unit.”[6]
He gave the following response when challenged:
Q.
But do you accept, doctor that those markers could also at the time that Mrs Craig is in the emergency department, equally represent a viral infection?
A. Well when you’re taking a bet, when you’re taking a bet on a patient’s life … I would much rather and I think that the aim for
treatment of sepsis is you give antibiotics and if it turns out to be
a viral infection, nothing was lost … but if you don’t give the
antibiotics, you can’t go back and give them at the appropriate
time.
Q. Well can I suggest that the time at which she should have definitely been given antibiotics was when it was obvious she was in shock at 3:30 pm? A. No you don’t wait until someone’s dying before you treat them.
In contrast, Associate Professor Dr Didier Palmer was of the opinion that the
picture was more complex and that raised inflammatory markers are just as
often associated with persons suffering viruses. In his opinion the indication
for antibiotics did not come until 3.30pm.
Mrs Craig remained in the Emergency Department. Her observations
remained relatively stable. Some appeared to improve a little. Her
temperature fell until at 3.20pm when it was 37.8. Her heartrate was at 90
beats a minute. Her blood pressure was fluctuating a little, albeit always
above a systolic pressure of 103. By 3.20pm she had received 2 litres of
normal saline. She still appeared to be dry. Her blood pressure was 110/50.
Her doctor was finishing his shift at 3.30pm. He transferred her to the ward
after the observations taken at 3.20pm. At the time of her transfer she wa s
receiving fluid at the rate of 125 milligrams an hour (8 hour bag).
There was no specific handover of the care of Mrs Craig at 3.30pm. At that
point there appeared to be no specific concerns. On arrival on the ward
further observations were undertaken. Her blood pressure had dropped
dramatically to 86/54 mmHg. Her heartrate was 102 beats a min, and heroxygen saturations were 95% on room air.
Mrs Craig was at that point in septic shock. So far as the information on the
sepsis pathway was concerned she fulfilled the criteria in the red section as
her systolic blood pressure had dropped below 90 mmHg. Her heartrate was
102 beats a minute. The pathway stated in the red section “this patient has
severe sepsis until proven otherwise”.
So far as the Adult Observation Chart used on the ward (between the flags)
was concerned, the drop in her blood pressure put her in the pink area. The
action required according to the Chart was that the RMO review the patient
within 30 minutes.
In the opinion of Dr Didier Palmer antibiotics should have been commenced.
He stated:
“The observations on the ward at 1530 should have resulted in
escalation and timely medical review and the commencement of
broad spectrum IV antibiotics (regardless of the lactate level – septic
shock can occur with a normal lactate) shortly after 1530 (within an
hour).”
A doctor was not however called at that time. Thirty minutes later the nurse
undertook another set of observations. Mrs Craig’s condition was
worsening. Her blood pressure had dropped further to 81/47 and her oxygen
saturations to 93%. The doctor was asked to attend. He ordered an
intravenous fluid bolus but did not attend. The fluid was given at 4.25pm.
At 5.00pm Mrs Craig had red and stinging hands. The nurse ceased the
intravenous fluids. An Emergency Department registrar (different to the
doctor who ordered the bolus of fluid) was seeing a patient nearby and was
asked to check on Mrs Craig by the nurse. The doctor re-sited the cannula
and obtained another Venous Blood Gas analysis. It showed that Mrs Craig
had a reducing pH (7.26) and rising lactate (4.2). According to the sepsispathway a lactate equal to or over 4.0 is one of the items in the red zone.
Repeat observations were conducted at 5.30pm. They showed a slightly
improved picture. Blood pressure was 93/62, heartrate was 90, temperature
was 37.0, respiratory rate was 22, and oxygen saturations 97%. Mrs Craig
said she was feeling better. The doctor spoke to the on-call doctor and the
commencement of antibiotics was considered. However it is clear that
neither doctor understood the full history of Mrs Craig while at Katherine
Hospital. It was decided to continue observations and repeat the lactate
analysis at 7.00pm.
At 6.30pm the observations showed a significant deterioration. Blood
pressure was 75/48, heartrate was 75, temperature was 36.6, respiratory rate
was up to 24 and oxygen saturations were down to 81%. There was a
thought that the low oxygen saturations might have been due to a bad trace
and they did not result in an emergency call.
Ten minutes later Mrs Craig was suffering diarrhoea and vomiting. She went
to the toilet and had dizziness. It was noticed that her lips were blue. The
medical emergency team was called. She was put on oxygen and given
fluids. At 6.48pm a Venous Blood Gas analysis showed her lactate to be 7.4.
She was returned to the Emergency Department (which for Katherine
Hospital is the most intensive care environment).
At 6.50pm Mrs Craig had another two bouts of diarrhoea. By 7.10pm it was
noted that Mrs Craig was clammy and peripherally shut down. At 7.20pm
antibiotics were finally commenced. From 7.40pm there was intensive
resuscitative efforts, but Mrs Craig went into cardiac arrest at 8.42pm and
was declared deceased at 9.25pm.
Reviews and Response
The failure to identify the deterioration was the subject of reviews by
Katherine Hospital, Top End Health Service and the Department of Health.
At Katherine Hospital improvements were sought to be made regarding
transfer and clinical handover of patients between the emergency department
and the ward, and upskilling in the identification of deteriorating patients
and the appropriate escalation of care.
Staff at the Katherine Hospital have made a video for continuing education
on the dangers of sepsis along with its identification and treatment. There
has also been personal learning from the doctors involved in Mrs Craig’s
care.
The doctor who first saw and admitted Mrs Craig said during evidence:
“I’ve thought about this case a lot over the last couple of years, and I
feel like in any physician’s career you’re going to have cases that do
affect your practice into the future, and feel that a case like this - and
having spoken to different intensivists and different specialists in
different areas, infectious diseases and intensivists, I feel like Iwould have a lower threshold in a situation like this to be giving
antibiotics earlier. Obviously that’s with the benefit of hindsight.
And I guess the reasons why [we] are trying to avoid giving antibiotics are things like increased, resistance to broad-spectrum
antibiotics; not knowing what you’re treating; there’s risk of giving
any medication, such as anaphylaxis … So those are all competing
factors. However, having spoken to different intensivists and different infectious diseases specialists, I feel like the risk of developing antibiotic resistance if giving a few doses of broad-
spectrum antibiotic early on in the patient’s course until you know
which direction they’re going in is less of an issue than I think the
medical profession thinks, and certainly that I thought at the time.”
The doctor who ordered the bolus of fluids after 4.00pm stated:
“We are genuinely affected when these things happen … my practise
has changed. It always will change. We will always continue to
upskill and hopefully minimise any repetitions of any of these sorts
of things ever happening again.”
The sepsis recognition pathway is being upgraded by the Top End Health
Service. Aboriginality has been included as a risk factor and there is an
indication that a lactate over 2.0 is significant after adequate fluid
resuscitation.
In May 2019 the Department of Health sought from the NSW Clinical
Excellence Commission (CEC) an assessment of the current systems for
“diagnosis and treatment of patients with sepsis in the NT”. That assessment
was completed in July 2019. The CEC made 23 recommendations relating to
governance, training, standardisation, system change and continual
improvement.
The Department of Health has developed a management plan for
implementation of the recommendations. Two of the milestones are said to
be the development of an NT Health Sepsis Management Pathway and an NT
Health Education Plan that includes a detailed strategy for Aboriginal
Health.
I commend Katherine District Hospital, the Top End Health Service and the
Department of Health on their efforts to ensure continual improvement in
combatting the challenges sepsis recognition and treatment poses since the
death of Mrs Craig.
Comment
Despite two inquests into the failure to identity sepsis at a Northern
Territory Hospital, the need for early intervention seemed not to have been
appropriately understood. Sepsis kills and it kills often. It is a very common
cause of death in hospitals. It is therefore incumbent on management to
ensure that the recognition of sepsis and its early treatment is appropriately
and continually reinforced and the understanding of its staff is audited.
For a patient who from the outset was recognised to be in potential danger
the documentation is very poor. There was for instance no fluid balance
chart utilised at any time. Given that urine output is a significant parameter
when identifying sepsis that seems less than adequate. Such a chart may also
have assisted the doctors to understand that they were unlikely to be been
dealing with hypovolemic shock after 3.30pm.
The death of Mrs Craig was likely to have been preventable.
One of the significant concerns of the family was that very early on in the
care of Mrs Craig the doctors understood that the infection was either viral
or bacterial. If viral, there was likely no real danger. If bacterial, there was
real danger. However, the consequences of withholding antibiotics was not
discussed with Mrs Craig or her family. The family are confident that if that
discussion were had she would have sought antibiotic treatment. In
circumstances where withholding treatment may well have had and did have
fatal consequences, that failure to discuss the options for treatment was
significant.
Pursuant to section 34 of the Coroner’s Act, I find as follows:
(i) The identity of the deceased was Joanne Craig born on 5
October 1960, Tennant Creek Hospital, Northern Territory.
(ii) The time of death was 9.25pm on 24 January 2018. The place
of death was Katherine District Hospital, Katherine in the
Northern Territory.
(iii) The cause of death was multi-organ failure due to sepsis that
was due to Streptococcus pneumoniae infection.
(iv) The particulars required to register the death:
1. The deceased was Joanne Craig.
2. The deceased was of Aboriginal descent. 3. The deceased was a manager of a cattle station. 4. The death was reported to the Coroner by a doctor at Katherine Hospital.
5. The cause of death was confirmed by Forensic Pathologist,
Marianne Tiemensma.
6. The deceased’s mother was Peggy Foster and her father was
Noel George Corp.
Recommendations
I recommend that General Practitioners have a schedule for and make every
effort to provide to Aboriginal and Torres Strait Islander people the
Pneumovax23 (23vPPV) vaccination in accordance with the Australian
Immunisation Handbook.
I recommend that the Top End Health Service do all things necessary to
ensure its staff are competent in the recognition of sepsis and escalation of
treatment and that such efforts are ongoing.
I recommend that the Top End Health Service do all things necessary to
ensure that the documentation utilised when treating patients is appropriate
and appropriately utilised.
I recommend that documentation utilised be audited on a regular basis.
Dated this 20 day of September 2019.
_________________________
GREG CAVANAGH
TERRITORY CORONER
ANNEXURE
Timeline of Events (from ED attendance 24‐01‐2018) from Dr Didier Palmer
(with my modifications)
Key
Nursing or medical assessment or actions
Observations
InvestigationsTreatment
Wednesday 24th January
Mrs Craig attends Katherine Hospital Emergency Department
0912hrs
Triaged: One day of fevers, vomited 4 times on the morning of presentation, global aching, cough for a month
Given an Australian Triage Scale (ATS) of 4 (to be ideally seen within an hour by a doctor)
0912hrs
Observations:
Temperature
39.9C Pulse
126
Respiratory rate 18
Blood Pressure 116/73Oxygen saturations 98% in air
0955hrs
Medical student (6th year) takes a comprehensive history for Dr Wyllie: Ms
Craig had been unwell from the previous evening when out to dinner with
fever and had vomited 4 times on the morning of attendance, she had
reduced oral intake. She also had a headache but no red flags for meningitis
(neck stiffness / photophobia / purpuric rash / contact history). She was
noted to work on a cattle station and had had a cough for a few weeks. She
had a diagnosis of hypertension and was on perindopril and
supraventricular tachycardia and was on metoprolol when this occurred.
She had been investigated inconclusively by a rheumatologist the previousyear for cutaneous systemic erythematosus and was an ex ‐ smoker and non-
drinker. Systems review revealed no obvious infective source.
On examination she looked unwell and lethargic and systems exam revealed her to be dry but otherwise no abnormality was found except a soft ejection murmur which had been noted from childhood.
CXR was normal (as reported in the notes I have not reviewed it myself )
Venous blood gas: pH 7.35; Co2 48 Na 141 K 3 Lac 2.3 HCO3 26.5
(performed 1035)
Blood tests requested (arrived in lab and registered at 1043): FBC / EUC /
LFT / CRP / Blood cultures / melioid serologyThe clinical impression was of a viral illness with no other clear infective source.
Initial management: ondansetron (anti‐ emetic) (prescribed 0915);
Ibuprofen (anti pyrexial) (prescribed 1100); IV access and IV fluids (1L normal saline prescribed 1050)
The above plan and investigation would have been discussed with Dr administration of drugs and fluids.
1100hrs
Nursing note: vomiting settled with ondansetron, vitally stable, plan: IV fluids, bloods, paracetamol
1100hrs
Treatment to this time: Antiemetic
Observations:
Temperature
39.7C Pulse 95
Respiratory rate 18
Blood Pressure 140/50Oxygen saturations 98% in air
1141hrs
Full Blood Count results available, results included:
White Cell Count 18.7 x 109/L (Normal 4.0 - 11.0) Neutrophil Count 14.2 x 109/L (Normal 2.0 - 8.0) Metamyelocytes 0.4 x 109/L (Normal 0.0) CRP 26 mg/L (Normal < 5.0)
1200hrs
Treatment to this time: antiemetic, up to 1L normal saline, ibuprofen
Observations:
Temperature
39C Pulse 103
Respiratory rate 20
Blood Pressure 120/50Oxygen saturations 93% in air
1220hrs
Second L of normal saline charted (commenced 1235)
1230hrs
1g of paracetamol given (charted at 1220)
1251hrs
Ward test urine: negative
1300hrs
Treatment to this time: antiemetic, 1‐ 1.5L normal saline, ibuprofen,
paracetamol
Observations:
Temperature 38.7C
Pulse 90
Respiratory rate 22
Blood Pressure 103/50Oxygen saturations 94% in air
1330hrs
Treatment to this time: antiemetic, up to 1.5‐ 2L normal saline,
ibuprofen, paracetamol
Observations:
Temperature 38.4C
Pulse 92
Respiratory rate 20
Blood Pressure 107/50Oxygen saturations 96% in air
1425hrs
Treatment to this time: antiemetic, 2L normal saline, ibuprofen and paracetamol
Observations:
Temperature
38.4C Pulse 89
Respiratory rate 20
Blood Pressure 105/50Oxygen saturations 94% in air
1425hrs
Dr Wyllie documents:
Treatment thus far: 2L IV fluids and 2 anti-pyretics (paracetamol and
ibuprofen):
Investigations: CRP 26; EUC 141/3.2/6.2/71; LFT alt 91 ggt 81; FBC134/.4/18.7 (n 18, lymph 0.6); U/A Protein + otherwise NAD
Plan:
a. Admit to inpatient ward for fluids/ antipyretics/ observation
b. 2nd set of blood cultures; full melioid screen
c. Not for antibiotics as does not fit severe sepsis criteria yet – improving but needs observation.
d. This plan was made in discussion with Dr O’Hern (the medical registrar on duty for inpatients and on call from home after 1630 for
the medical inpatients)
1430hrs
Dr Wyllie charted IVT N/Saline with 20 mmol KCl to continue @ 125 mls/hr
1520hrs
Observations (pre-departure from the ED):
Temperature
37.9C Pulse 92
Respiratory rate 24
Blood Pressure 110/50Oxygen saturations 96% in air
1530hrs
Arrives on the inpatient ward transported on a wheelchair, noted to be alert
and orientated. The nurse notes the patient to be hypotensive on arrival
observations at 1530 and s/he repeats the observations at 1600hrs and they
show the patient is still hypotensive. At that point s/he escalates to the
(ED) doctor by phone.
1530hrs
Observations (post arrival on inpatient ward):
Temperature
37.4C Pulse
102
Respiratory rate 24
Blood Pressure 86/54Oxygen saturations 95% in air
1600hrs
Observations:
Temperature 37.2C
Pulse 90
Respiratory rate 20
Blood Pressure 81/47Oxygen saturations 93% in air
1625hrs
The contacted ED doctor gives a telephone order for 1L of Hartmanns solution to be given as a bolus. The nurse noted the patient to be comfortable.
1710hrs
The patient buzzed due to pain in both hands, Hartmanns solution was ceased
Observations:
Temperature
37.2C Pulse 90
Respiratory rate 20
Blood Pressure 89/46Oxygen saturations 93% in air
The medical officer was called again
1730hrs
Observations:
Temperature 37C Pulse 90 Respiratory rate 22
Blood Pressure 93/62
Oxygen saturations 95% in air
1730hrs
Up to this point the patient had had 2‐ 3L crystalloid
The ED registrar left the ED and attended the patient on the ward. He noted
no source of infection but she felt cool peripherally, felt subjectively
better, was afebrile, was making urine and was not confused and had a risein lactate to 4.5
The registrar discussed the case with Dr O’Hern who elected to observe and
repeat the lactate at 1900hrs and not give antibiotics
1830hrs
Observations:
Temperature
36.5C Pulse 75
Respiratory rate 22
Blood Pressure 75/48
Oxygen saturations 81 % in air with poor trace
The nurse documents that the patient was slightly short of breath and also had diarrhoea and was assisted to the toilet. A medical officer was on the ward reviewing another patient and the nurse was advised to repeat the
observations on the patient’s return from the toilet. When in the toilet the
patient had an episode of vomiting post toileting and her lips went blue
(cyanosis). She was brought back to her bed, commenced on oxygen andthe foot of the bed raised and a rapid response was called.
1910hrs
MET Call (emergency response medical call)
Medical officer notes pre‐ syncope, low blood pressure, peripherally shut
down, delayed capillary refill; all signs of cardiovascular collapse (shock)
despite the patient still mentating normally.
500ml bolus Hartmann’s and transfer back to ED (with a delay documented
as the patient was using the pan).
1930hrs
The patient was transferred back to the ED and the notes document her arrival in the ED at 1930
At that point the diagnosis was of decompensated septic shock and there was a very experienced medical team comprising a consultant emergency physician, an accredited emergency medicine advanced trainee, a GP
anaesthetist and a junior medical officer.
The patient was initially mentating normally with a blood pressure of over 100 systolic and a heartrate of about 100. Central venous access was attempted but proved not possible. Wet season severe sepsis antibiotics were given (meropenem and vancomycin) and peripheral inotropes commenced.
Ms Craig continued to deteriorate rapidly and lost output (went into cardiac arrest). Standard Advanced Life Support protocols were followed and she was intubated and ventilated. There was a brief return of circulation but there followed diminishing response to inotropes and further cardiac arrest.
Stephen (Ms Craig’s partner) was brought into the resuscitation and there
was discussion with him regarding the futility of further resuscitative
effort.
2125hrs
Resuscitation was ceased at 2125hrs with Stephen in the room.
Family members arrived to support Stephen at 2143.
[1] Report of Dr Raftos p10
[2] Ibid p 11
[3] Ibid p11
[4] Published by the Australian Government Department of Health
[5] Transcript p42
[6] Report dated 24 December 2018, p 12
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