Date of Findings: 9 June 2017 

Coroner: Ainslie Kirkegaard

Inquest Place: Brisbane

Date of Death: 2 February 2015

Issues for Consideration:

  1. Whether heart failure was the primary cause of DR’s death
  2. Whether sufficient care was taken by the Prince Charles Hospital to manage and treat DR’s chronic health issues in partnership with DR’s carers.

Factual Summary:

DR was a 46 year old woman found unresponsive in her funded disability supported accommodation room by a carer on 2 February 2015. She had a long history of mental illness and chronic health problems including diabetes, obstructive sleep apnoea and obesity.

She presented to the Prince Charles Hospital a number of times between 1 January 2015 and 17 January 2015 with health issues including high Blood Glucose Levels, Hypertension and Obesity Hyperventilation Syndrome.

The autopsy revealed evidence of dilated cardiomyopathy which the pathologist considered caused the death. This condition can lead to death by progressive heart failure or by a sudden abnormal heart rhythm.

Prince Charles Hospital Internal Medicine Morbidity & Mortality Meeting

  • Dr M’s case presentation note disclosed that the discharge summary for DR’s final admission was in fact not completed until almost two months following her discharge from hospital (this being almost one month after her death). It was prepared by a junior doctor who was not involved in her care. This meant that clear instructions were not conveyed to DR’s general practitioner regarding ongoing monitoring of her diabetes in the community, including when to seek further medical attention (and not available to Dr J when she saw DR on 22 January).
  • DR spent more time in the emergency department than on the ward with her definitive treating team in her last two admissions and the level of documentation reflected this with admission being an implied concern by emergency department staff that she required inpatient management.
  • This raises the question of whether these two admissions provided an appropriate timeframe to assess DR’s presentations at the time and fully differentiate her clinically, as well as allowing for appropriate patient education, carer education and assessment of whether she was safe for discharge. The reviewing doctor considered both admissions fell far short of reasonable in the circumstances.

Prince Charles Hospital Formal Clinical Review

  • There had been appropriate focus and clinical work up of DR’s respiratory issues in consideration of the diagnosis of pulmonary hypertension. A discharge summary was provided to her general practitioner advising of the need to continue to manage DR’s diabetes according to “usual” guidelines.
  • There were several missed opportunities to improve care planning after DR’s mental health admission which were considered to have contributed to her multiple night time presentations to the emergency department for the administration of insulin.
  • Ongoing education and support of DR’s carers, along with liaison with her general practitioner was not evident in the hospital discharge summaries or the medical record.
  • DR’s intermittent hyperglycaemic episodes were undoubtedly the result of non-compliance, variable diet and self-cares and insufficient communication from the hospital to the general practitioner.
  • Ongoing education and support of DR’s carers, along with liaison with her general practitioner was not evident in the hospital discharge summaries or the medical record.
  • TPCH has commissioned a discharge summary quality improvement project due to concerns about its ability to meet the communication needs of its community. This project will incorporate the importance of medical handover as a focus in after-hours discharges.


DR died from an acute complication of her underlying dilated cardiomyopathy

  • DR’s chronic mental health issues impacted significantly on her willingness and ability to comply with a range of social and health interventions to enhance her well-being and to manage her insulin-dependent diabetes and obstructive sleep apnoea.
  • While DR’s respiratory issues were investigated appropriately over November 2014 – January 2015, her multiple emergency department presentations and admissions to The Prince Charles Hospital over this time represented missed opportunities to consider her care holistically.
  • While the management of DR’s last two hospital admissions in January 2015 was less than optimal, the Coroner was satisfied it neither caused nor contributed significantly to her death. This is because the autopsy findings indicate she died from an acute complication of her dilated cardiomyopathy (sudden cardiac arrhythmia) rather than as a result of heart failure or a complication of her diabetes. However, the hospital’s failure to communicate with and educate DR’s carers (who were not clinically trained) about her condition and to liaise with her general practitioner in a timely and informative way impacted on the management of her diabetes, which was clearly challenging.


The events leading to DR’s death demonstrate the importance of treating doctors providing clear information and instructions to non-clinical carers in order to help ensure the patient’s treatment is continued on discharge from hospital, that the patient remains compliant and that medical follow up is undertaken, together with clear instructions regarding action plans/emergency management. The Prince Charles Hospital has now recognised this deficiency in its delivery of care to DR and has prioritized action to improve discharge summary quality and to examine improvements to the coordination of care in after-hours settings.

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