Coroner's Court of Western Australia

Inquest into the Death of Roderick Leslie CARTER

Inquest into the Death of Roderick Leslie CARTER

Delivered on :15 March 2018

Delivered at : Perth

Finding of : Deputy State Coroner

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased presented at the Cunderdin Hospital and was admitted into the emergency department for investigations of his symptoms. In the process of those investigations commencing the deceased suffered a cardiac arrest and died on 13 October 2014.  The deceased was 63 years of age.

The deceased and his wife arrived at the hospital by car at approximately 10.54pm on 12 October 2014. The deceased complained of chest pain and stated he had been experiencing chest pain for the past three hours.  Assessment for triage commenced at approximately 11.00pm, the deceased’s file was retrieved and a basic set of preliminary observations were performed.  In view of the deceased’s symptoms staff commenced completing the WACHS emergency chest pain assessment pathway which included taking ECGs.  The protocols in place required ECGs to be faxed to a doctor for interpretation and instructions as to how to manage the patient.  There was no after hours doctor available at the hospital and medical input had to be sought from external sites.

The focus of the inquest was on the review of some systemic concerns with respect to processes in place at the hospital to deal with sudden cardiac arrests.

The Deputy State Coroner was satisfied staff appropriately identified the deceased was possibly suffering a myocardial infarction and provided the deceased with aspirin and Nitroglycerin spray. In accordance with Chest Pain Pathway protocol staff performed an ECG but believed appropriate documentation needed to be provided to a medical practitioner in order to seek assistance.  In the circumstances of the deceased it would have been appropriate for medical input to be sought without documentation but this was not as clear in 2014 as there is now a 24 hour emergency televideo medical service available to remote hospitals without on site medical practitioners. The Deputy State Coroner noted the reviewing cardiologists in this case all agreed that once the deceased had arrested the administration of preventative therapies were irrelevant.

The Deputy State Coroner found the death occurred by way of Natural Causes.

Catch Words : Emergency Telehealth Service : Training : Contact with Metropolitan Tertiary Hospital for Remote Nurses : Natural Causes.

Last updated: 30-Apr-2019

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