CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland.

CORONIAL HEALTH CARE RELATED DEATHS

Dr Don Buchanan

Forensic Medical Officer

Queensland

PURPOSE

To help prevent deaths from similar causes happening in the future

REPORTABLE DEATHS

• “Reportable Deaths” must be reported to –– Coroner– Police officer

• Death in custody only reported to State Coroner or Deputy State Coroner

• If death reported to police officer because a death certificate has not or is likely not to be issued, police officer can wait until satisfied this is or will be the case

CRITERIA FOR REPORTABLE DEATHS

Geographical

Category of death

GEOGRAPHICAL

Death happened in Qld.

Death happened elsewhere but– Body of deceased in Qld, or– At time of death person ordinarily lived in Qld, or– At time of death person was on a journey to or from

somewhere in Qld, or– Death caused by an event that happened in Qld

However death outside Qld, not reportable if it has already been reported to a non-Qld coroner.

If the death occurred outside Australia, coroner not to investigate unless directed by the Minister

NATURE OF DEATH

• Person unknown• Violent or otherwise unnatural death• Suspicious circumstances• Death a health care related death• Death certificate not issued and not likely

to be issued• Death in care• Death in custody• Police operations

VIOLENT OR UNNATURAL DEATHS

Violent generally clear

Unnatural traditionally – accident, suicide or homicide

Three broad categories of unnatural deaths

– Effects of chemicals eg alcohol, drugs and poisons

– Deprivation of air, food, water such as asphyxia, drowning, dehydration, starvation

– Physical factors such as trauma, cold, heat, fire, electricity, radiation

?UNNATURAL DEATHS

Doctrine of Double Effect– Intention/Foresight Distinction

Withholding/Withdrawal of Medical Treatment– Act/Omission Distinction (Re: B; Bland’s case)

SUSPICIOUS DEATHS

Initial cause of death uncertain

Concern about surrounding circumstances

HEALTH CARE RELATED DEATH

“Health care” means a health procedure or any care, treatment, advice, service or good provided for the benefit of human health


“Health procedure” means a dental, surgical or other health related procedure, including for example the administration of an anaesthetic, analgesic, sedative or other drug


Death under this category reportable if –

(1) Health care likely caused or contributed to death;

AND

(2) Immediately before health care provided, independent person would not have reasonably expected the health care would cause/contribute to the death


Death under this category reportable if -

(1) Failure to provide health care likely caused or contributed to death;

AND

(2) When health care sought, independent person would not have reasonably expected the failure to provide the health care that would cause/contribute to the death


Independent person is to have regard to all relevant matters including –

• Deceased’s state of health as it was thought to be when health care begun or sought;

• Clinically accepted range of risk associated with the health care;

• Circumstances in which health care was provided or sought.


Ask TWO basic questions

1. Did the health care cause or contribute to the death?

2. Was the death from the health care not reasonably expected?



• Would the person have died at about the same time without the health care? Y/N

• Did the death result directly from the underlying disease or injury? Y/N

• Was the health care carried out with all reasonable care and skill? Y/N

If all answered “yes”, then procedure did not cause or contribute to the death


2. Was the death not reasonably expected?

• Before health care was provided, was the patient’s condition such that the death was foreseen as more likely than not to occur? Y/N

• Was the person told that death was foreseen as more likely than not to occur? Y/N

• Was the decision to provide the health care reasonable given the person’s condition, including their quality of life, if the health care was not provided? Y/N

If all answered “yes”, then death was reasonably expected


For failure cases ask two basic questions -

1. Did the failure to provide health care cause or contribute to the death?

2. Was the failure to provide health care that caused/contributed to the death not reasonably expected?

CORONER CAN CEASE INVESTIGATING A REPORTABLE DEATH

• If a death is reportable but coroner considers no autopsy and no further investigation required

• Can authorise doctor to issue routine (non-coronial) cause of death certificate

• Treating doctor must complete a Form 1A with summary of deceased’s last illness attached

ROLE OF CLINICAL FORENSIC MEDICAL OFFICER

Review deaths pursuant to a Form 1A and advise if reportable or not reportable;

- if reportable, advise whether autopsy and further investigation is warranted (or not).

Where autopsy ordered and further investigation commenced, advise on the clinical and/or toxicological aspects of the death

Case 1

• 56 year old woman• Admitted for biopsy cerebral tumour• Frozen section – anaplastic malignancy

(severely abnormal cells)• 6 hours post op - decreased LOC, intubated,

ventilated• Urgent CT - haemorrhage into tumour• Decision in consultation with family (in view of

histology) was not to operate again – brain death

Case 1

Form 1A to the coroner

Interim Death Certificate stated -• 1(a) Cerebral Oedema• 1(b) Right Anaplastic Cerebral Tumour

Reportable or Not Reportable?

Case 1


• Would the person have died at about the same time without the health care? Ans: N

• Did the death result directly from the underlying disease or injury? Ans: N

• Was the health care carried out with all reasonable care and skill? Ans: Y

Hence health care caused/contributed to the death

Case 1


• Before the health care was provided, was the patient’s condition such that the death was foreseen as more likely than not to occur? Ans: N

• Was the person told that death was foreseen as more likely than not to occur? Ans: N

• Was the decision to provide the health care reasonable given the person’s condition, including their quality of life, if the health care was not provided? Ans: Y

Hence the death was not reasonably expected.

Case 1

Suggested Death Certificate• 1(a) Cerebral Oedema• 1(b) Haemorrhage into Anaplastic

Cerebral Tumour• 1(c) Biopsy of Anaplastic Cerebral

Tumour

Case 2

• 66 year old Male• PH – COPD, AVR, carcinoma colon• Admitted for right hemicolectomy• Post op – ICU – wound infection - sepsis –

settled after 10 days sufficient for discharge to ward

• CVL required replacement – At 1800 hours a R subclavian approach – check CXR ordered;

• 0200 hours ward call ATSP re SOB - ?CCF ?COPD – given diuretics, bronchodilators – minimal effect – then arrests and dies

Case 2

Form 1A to the coroner

Interim Cause of death certificate stated -• 1(a). Respiratory Failure• 1(b). Acute exacerbation COPD

• 2. Carcinoma colon

Reportable or Not Reportable?

Case 2

• Copy of medical notes received• No documentation made at the time when

central line was replaced – written in retrospect

• No note made at any time that CXR was seen• CXR showed R pneumothorax• A pneumothorax not considered by doctors

treating him for the acute SOB episode prior to death (supported by interim Cause of Death Certificate)

Case 2


• Would the person have died at about the same time without the health care? Ans: N

• Did the death result directly from the underlying disease or injury? Ans: N

• Was the health care carried out with all reasonable care and skill? Ans: ?Y

Hence the health care (ie replacement of central line) caused/contributed to the death.

Case 2


• Before the health care was provided, was the patient’s condition such that the death was foreseen as more likely than not to occur? Ans: N


• Was the decision to provide the health care reasonable given the person’s condition, including their quality of life, if the health care was not provided? Ans: Y

Hence the death from the health care was not reasonably expected.

Case 2

Suggested Cause of Death Certificate• 1(a) Respiratory failure• 1(b) Right sided pneumothorax• 1(c) Insertion right subclavian central venous

line• 2. carcinoma colon, chronic obstructive

pulmonary disease

Case 3

• 80 year old male• PH – CCF, COPD, OA• PC – sudden onset severe epigastric pain previous 2

hours; rigid abdomen, free air in abdomen; febrile• Laparotomy – perforated DU; successfully repaired;

sent to ICU• Post op – cardiogenic shock treated with inotropes,

settles over 5 days; extubated; sent to ward• Next day spikes fever, AF, hypotensive episode• Resuscitated; re-admitted to ICU diagnosis sepsis;• Despite inotropic support and IV antibiotics - dies

Case 3

• Form 1A to coroner• Interim death certificate states –• 1(a) Multi organ failure• 1(b) Abdominal sepsis• 1(c) Perforated duodenal ulcer• 2. Congestive Cardiac Failure, COPD

Reportable or Not reportable?

Case 3


• Would the person have died at about the same time without the health care? Ans: Y

• Did the death result directly from the underlying disease or injury? Ans: Y

• Was the health care carried out with all reasonable care and skill? Ans: Y

Hence the health care did not cause/contribute to the death.

Case 4

• 59 year old man presented with chest pain to local country hospital one evening

• Discharged next morning pain free• Advised to see LMO in 2 days for follow up• LMO diagnosed chest wall pain• Found dead next morning – police called• LMO prepared to complete death certificate

as MI being the cause of death given his pain and past medical history

Case 4

Form 1A to coroner

Interim death certificate stated –

1(a) Myocardial Infarction

Case 4

Hospital Medical Record• Pain came on after lifting and was 9/10 severity• Initially was sharp then dull not associated with

nausea, cough, fever or palpitations• No PMH, FH recorded• Smoker, on no medication• Examination records normal heart sounds and

the chest was clear• Troponin was negative• No CXR or other test

Case 4

Hospital Medical Record• But CXR report done 12 months earlier

documenting cardiomegaly• Discharged pain free next morning with

advice for follow up with LMO• Follow up recommended exercise stress test,

cholesterol test and maybe CXR

Case 4

LMO Medical Notes

• Seen 2 days later with history of episodic but continuing pain

• Notes document patient had family history of heart disease

• History of borderline hypertension, raised cholesterol, and indeed was a smoker

• Examination consisted of sternal palpation - was tender - Nil other examination recorded

• Chest wall pain diagnosed

• Given NSAIDs

Case 4

LMO Medical Notes• An entry noted he had had a CT Angiogram of

thoracic aorta at a provincial hospital 18 months earlier after being struck by a car

• GP was requested to provide her copy of this report

• Report documented a dilated aortic root 5.5cm diameter, longstanding, and report recommended further investigation with ultrasound

Case 4

1. Did the failure to provide health care cause or contribute to the death?

• Would the person have likely died if the health care had been provided? Ans: N

• Was the underlying disease or injury such that it was not amenable to the health care that was sought? Ans: N

• Was the health care that was actually provided carried out with all reasonable care and skill? Ans: N

Hence the failure to provide health care caused/contributed to the death.

Case 4

2. Was the failure to provide health care that caused/contributed to the death not reasonably expected?

• When the health care was sought, was the patient’s condition such that the death was foreseen as more likely than not to occur? Ans: N


• Was the decision not to provide the health care reasonable given the person’s condition at the time? Ans: N

Hence the death from the failure to provide health care was not reasonably expected.

Case 4

• Reportable• Given the information provided, further

examination recommended• Hence interim death certificate not accepted

Case 4

Autopsy revealed a type A aortic dissection (dissecting aortic aneurysm) with cardiac tamponade (600ml)

Case 4

Advice• Dangers of use of retrospectocope• Dissecting aortic aneurysm difficult to

diagnose• But inadequate history taking, physical

examination, investigation, limited the chance of diagnosis

• And there were hints

THE END

Case 5

45 year old woman carcinoma rectum• Routine admission for anterior resection and loop

ileostomy• No significant PMH; on no medications• Pre-op PR 84; BP 140/85; Hb 120; Plts 386

Operation• Notes do not reveal any technical issues or intra-

operative bleeding• Given heparin 5000 units S/C at conclusion of

procedure

Case 5

Recovery• PR 90/min; BP 130/65; RR 18• Minimal drainage • Obs stable over 2 hours• PCA morphine 1mg/1ml• RTW awake and stable after 2 hours in

recovery

Case 5

Ward• RTW at 1500 hours• Obs done at 1530 wnl• Next obs at 1730 wnl• Next obs at 2000 – BP 86/60• No further obs documented• Nursing note entered at 2030 stated “drowsy but

rousable during shift, hypotensive at times..”

Case 5

Ward• At 0030 hours found to be in cardiac arrest• Asystole –CPR, adrenaline, ROSC but

unconscious with fixed dilated pupils• Surgeon at 0100 noted no abdo distension

and minimal drainage - initially considered PE, CVA

Case 5

ICU• At 0130 Hb 68 (from 120) Plts 125 (from 386)• Now 500 ml blood from drain• Considered to have suffered blood loss and

coagulopathy• By 0600 had been given 8 units blood, 4 units

FFP, platelets• By 0800 a further 2500 ml blood had drained• GCS 3 without sedation – considered likely she

had suffered hypoxic brain injury

Case 5

ICU• Coagulopathy considered to be DIC from

shock secondary to cardiac arrest• Queried whether intra-abdominal

haemorrhage was due to CPR given (overt) bleeding occurred after CPR

• Surgeon sought second opinion during course of morning re laparotomy – in view of likely brain injury considered futile

Case 5

ICU• Continued to bleed throughout day – further 4

units PRBC, 4 units FFP, 20 units cryoprecipitate, 4 units platelets

• Neurologist examination at 1300 noted no neuro improvement over 12 hours, GCS 3 without sedation, no focal defects suggestive of intra cranial haemorrhage – likely hypoxic brain injury with poor prognosis

• Treatment withdrawn 1730

Case 5

Post mortem• 3000 ml unclotted blood in abdomen• Anastomosis intact; no injury to organs or

blood vessels found• Fat emboli found in lungs• Cause of death considered to be intra-

abdominal haemorrhage due to surgical complications.

Case 5

When did the bleeding occur?• Cause of death diagnosis indicates it occurred

before cardiac arrest• Unrecognised by deficient monitoring and a lack

of blood in the drain• Blood loss caused cardiac arrest, which caused

coagulopathy and the hypoxic brain injury • No CPR injuries found hence considered due to

surgery

Case 5

When did bleeding occur?• But no cause of bleeding from surgery found

either• CPR may hence have caused the bleeding • What then caused the cardiac arrest?

Case 5

What about fat embolus?• Fat embolus syndrome includes hypoxia,

consumption of platelets and DIC• Mostly found after long bone fractures but

seen in cancer• Fact is that fat emboli seen at autopsy• Pathologist stated this can be a non-specific

finding hence considered unlikely

Case 5

Recommendations• Decision not to operate reasonable in the

circumstances• Hospital urgently review its policies and

procedures re post-operative monitoring• Hospital conduct remedial training specifically

and on-going training generally• Staffing levels be assessed

THE END

CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland.

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