The Victorian Institute of Forensic Medicine has recently published an article including coroner findings  regarding the deaths of two patients in 2009.The  cases were heard as concurrent inquests into the deaths of two patients. The two patients were not known to each other, but they had both died in rural hospitals from complications associated with Influenza A H1N1 2009, pandemic swine flu. This first post discusses one of the cases and the next post will highlight key recommendations regarding Swine flu 10 years on!

 Ms CF i. Clinical Summary

Ms CF was a 41 year old female who did not have any significant past medical history. She presented in the early evening to a medical clinic with a four day history of flu-like symptoms, loss of appetite, and lethargy. The night before she presented, she had developed diarrhoea, nausea and dry-retching. At the clinic, Ms CF was seen by a general practitioner (GP) registrar (Dr V) who noted that she looked pale and dehydrated.

On examination, she was febrile (temperature was 38.9 degrees Celsius) and tachycardic (heart rate was 121 beats per minute). She had a red throat but did not report any respiratory symptoms. Dr V diagnosed her with viral gastroenteritis and made arrangements for her to be admitted under his care at the local hospital for intravenous rehydration. On admission, Ms CF’s blood pressure (BP) was 108/66 mmHg. Over the course of the evening she received over two litres of intravenous fluids but was progressively more hypotensive with a BP reading at 10pm of 81/53 mmHg. Her tachycardia and temperature settled and she told the nurses she was feeling better. At midnight, her BP was 75/54 and at 2am, the nurse on duty called Dr V to report that Ms CF’s BP had dropped to 72/46 mmHg.

Dr V instructed the nurse to administer a 500ml bolus of saline over two hours and call him back if there were any concerns or changes. Dr V reviewed Ms CF at 8:25am that morning and noted that her BP at 4am had been 75/46 mmHg and at 6am was 87/53 mmHg. She looked flat, and complained that she felt worse and was still experiencing diarrhoea. Dr V maintained a working diagnosis of gastroenteritis and made a plan for the nurses to continue with intravenous fluids and administer fluid boluses as needed. He then left the hospital to attend to his clinic patients. Ms CF’s blood pressure remained low throughout that day despite fluid therapy.

At 4:45pm, nursing staff became concerned that she had deteriorated and was looking pale and clammy, and was grunting. Her BP had suddenly increased to 150/128 mmHg. The nursing staff contacted Dr V who advised he would review Ms CF as soon as his clinic was finished. In the meantime, he indicated that they should slow the rate of the intravenous fluids. Dr V then spoke to Dr A, a GP anaesthetist at the same clinic, who went to the hospital to see Ms CF. Dr A arrived at the hospital just over an hour later, and found Ms CF cold and shutdown with a systolic BP of 70 mmHg. She was alert but agitated and in obvious respiratory distress.

Dr A called for immediate assistance and began administering adrenaline with little improvement. Dr A proceeded to intubate Ms CF and make arrangements to transfer her to a metropolitan intensive care unit, however she arrested and did not respond to cardiopulmonary resuscitation. She was pronounced deceased at 8pm.

Pathology

A forensic pathologist conducted a post-mortem examination of Ms CF and reported her cause of death as being due to Influenza A (H1N1 2009, pandemic swine flu) after detecting the virus on a specimen of lung tissue. The forensic pathologist also found evidence of viral myocarditis and pulmonary oedema.

Investigation The coroner held an inquest to consider whether different clinical management and support would have led to an accurate diagnosis for Ms CF and her condition being treated effectively. A senior emergency physician provided written and oral expert evidence in relation to Ms CF. The expert stated that at the time, it was reasonable for Dr V to not have considered H1N1 as a differential diagnosis for Ms CF’s illness. The expert qualified however, that irrespective of the diagnosis, the persistent hypotension exhibited by Ms CF should have triggered close observation with continuous monitoring, and aggressive investigation of the potential underlying causes with reconsideration of the provisional diagnosis.

It was the expert’s opinion that inotropic therapy, escalation of care, and retrieval to a tertiary hospital ought to have been considered much earlier. The expert also offered an opinion on the view taken by the nurses that the unexplained low blood pressure readings in the context of an improved clinical picture was not cause for alarm.

The expert submitted that deriving reassurance on the basis of conscious state was a flawed approach.

The expert considered that Ms CF was exhibiting a shock state, which is an uncommon finding in viral gastroenteritis. The coroner drew attention to the fallacy of the fluid bolus order, pointing out that the infused amount would have equated to only 250mls by the end of the first hour.

The coroner expressed concern about Dr V’s directions to the nursing staff to be contacted in the event of a change rather than if there had been no change to Ms CF’s condition, and the lack of explicit instructions regarding the monitoring and management of Ms CF’s blood pressure. Dr V’s misguided sense of comfort at the elevated BP failed to take into account her progress in the hours since he had seen her, or to recognise the severity of her condition.

Coroner’s Findings

The coroner found that at the time of Ms CF’s admission to hospital, she was suffering from the effects of swine flu. The coroner also found that Ms CF’s persistent hypotension was reflective of myocarditis, a process that was not recognised by the clinicians. The coroner was not critical of the failure to diagnose myocarditis, but indicated that regardless of the perceived reason for the low blood pressure, it should have been cause for much greater concern. The coroner stated that Ms CF’s management in hospital was sub-optimal and her chances of survival would have been much greater, had she been provided with optimal support or retrieved to a tertiary hospital.

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The Clinical Communiqué is an electronic publication containing narrative case reports about lessons learned from Coroners’ investigations into preventable deaths in acute hospital and community settings. The Clinical Communiqué is written by clinicians, for clinicians. The Clinical Communiqué was first published in 2003.
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