On 14 June 2019, the Coroner's Court of New South Wales released its findings into the death of Melissa King. The circumstances of her death highlight the risks associated with the use of electronic progress notes as a means of communicating concerns about the treatment decisions made in respect of patients.

Background

Ms King was 33 years old at the time of her death at Blacktown Hospital. On Wednesday 10 August 2016, she had called the National Home Doctor Service on account of having vomiting and diarrhoea for two to three days. The service referred her to Mount Druitt Hospital from which she was transferred to Blacktown Hospital. She had a history of chronic alcohol use and malnutrition, weighing 40kg upon her admission to hospital.

At Blacktown Hospital, she was treated with fluid and electrolyte replacement and was admitted to the ICU. She was ultimately diagnosed with urinary tract sepsis, severe malnutrition with electrolyte metabolic derangements, notable low sodium and a number of other micronutrients, deranged liver function and ascites, pulmonary effusions and obstructive renal calculus diagnosed by CT. Further investigations into the cause of her symptoms were arranged. A CT scan showed bowel wall thickening which suggested inflammatory bowel disease.

In replenishing her depleted micronutrients, one consideration for her treating team was the risk of ‘re-feeding syndrome' whereby a malnourished person who starts receiving artificial refeeding is at risk of a potentially fatal shift in fluids and electrolytes. That risk was identified in the records. There was fluctuation in her response to refeeding and also in relation to her overall condition. She had periods of lucidity, deterioration, confusion and agitation. On 15 August she began complaining of ongoing abdominal discomfort. An endocrinology registrar noted that her abdomen was distended and bowel sounds were difficult to hear.

The intensive care specialist decided to transfer her to the ward. Ms King had been tachycardic for most of her admission and the endocrinology and gastroenterology teams felt that it was not safe for her to be transferred while this remained unexplained, recording their opposition to this decision in the progress notes. The specialist also altered Ms King’s calling criteria so that a review would only be triggered upon her heart rate exceeding 130 bpm. The endocrinology and gastroenterology teams were not informed of the ultimate transfer, nor of the alteration to the calling criteria.

It was intended that Ms King would have an endoscopy on 17 August. Upon admission to the ward, she began her preparation, which required her to consume a glycoprep solution. She was also reviewed by an anaesthetist trainee. The trainee identified a wheeze for which Ms King required a bronchodilator. Her oxygen saturation also dropped, and a nurse was advised to increase her oxygen supply, 3L/min via nasal prongs.

Later in the evening, Ms King told a nurse than she felt hot and cold. She was still short of breath. The nurse asked a doctor to review Ms King and that doctor asked the nurse write a note requesting the after-hours doctor to review the patient. No review followed.

Before midnight, Ms King called for a bedpan and continued drinking the grycoprep solution. At 11:58 she was found unresponsive. Cardiopulmonary resuscitation was commenced and a tracheostomy was inserted,. On 13 September at a family conference it was decided that the tracheostomy be removed and palliative care provided. Ms King passed away on 16 September.

An autopsy showed that Ms King’s cause of death was hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiopulmonary arrest and resuscitation. Chronic alcoholism with liver disease and malnutrition with refeeding syndrome were also seen as significant conditions contributing to the death.

Findings

The experts were critical of the management of micronutrient replacement, saying that it was not well coordinated. The risk of salt and water retention with re-feeding syndrome was not managed appropriately. Ms King’s fluid administration plan should have been adjusted after her fluid balance was positive and later when there were signs of severe fluid retention. Instead, her treatment caused gross fluid and sodium overload, evidenced by oedema, ascites and bilateral pleural effusions.

There was miscommunication in the decision to transfer Ms King to the ward. The endocrinology and gastroenterology teams entered their opposition to the decision to transfer her in the progress notes. One doctor of the endocrinology team also raised his opposition in discussion. There were discrepancies in evidence about whether those notes voicing opposition were seen by the ICU Registrar. The coroner accepted one expert’s observation that 'the electronic record is a valuable repository of information but a poor and dangerous communication tool'. In was inappropriate that the notes citing opposition to transfer were not seen and that relevant teams were not notified of the decision to transfer the patient.

Two experts in particular were critical of the decision to transfer Ms King, given the gross fluid and sodium overload which was evident at this time, coupled with the tachycardia. These should have been urgently managed. It was explained that reefing syndrome is associated with sudden cardiac death. While two teams were concerned with transfer on the basis of tachycardia, the bigger problem was the fluid and sodium overload. No one identified the main concern.

The transfer summary was incomplete and unsigned. It did not refer to the risk of re-feeding syndrome, nor to the persistent sinus tachycardia. One expert noted that the decision to organise endoscopy was unwarranted and unwise in light of Ms King’s worsening condition. It evidenced an unnecessary focus on inflammatory bowel disease. The glycoprep mixture was inappropriate for an oedematous patient. On the whole, however, the Coroner decided not to criticise the decision.

Systemic Issues

The Director of Medical Services for Blacktown Hospital gave evidence of the changes to practice and procedure, which were incorporated following a review of the circumstances around her death. These included a new clinical emergency response system being introduced, resulting in extensive education across hospitals. Over 100 sessions were conducted. An additional medical registrar is now rostered for weekday evenings to ensure the necessary expertise level. Additional critical care senior registered medical officers have been rostered for after-hours shifts. Funding has been allocated for an additional intensive care consultant.

A structured ‘medical and nursing pathway’ to transfer patients has been developed and implemented. Verbal clinical handovers are required. In addition, improvements are being made to the electronic medical records.

In the circumstances of the hospital’s improvements, the Coroner did not propose to make any recommendations.