VOLUME 4 ISSUE 4.
Welcome to the final edition of the Coronial Communiqué for 2006. As promised we have altered the layout to make it easier to read. The content and our approach to the cases
The Coronial Communiqué now has an ISSN number. This means it is registered and
catalogued with the National Library because the content is of national significance. The
entire back catalogue will be available through the National Library next year.
A sister publication, the Residential Aged Care Coronial Communiqué, was launched
in early October by the Victorian Minister for Aged Care, Gavin Jennings MLC. This
specialised Coronial Communiqué will highlight significant safety issues that arise
during the investigation of the death of older people. The first issue examined the use
of physical restraint and can be found at http://www.vifm.org/research_cls.html. If you would like to subscribe to the Residential Aged Care Coronial Communiqué you need to
Medications: Double Checking at the Bedside? 4
We are undertaking a review of our communication strategies and exploring options for
expanding the Open Days to cover the entire spectrum of activities at the State Coroner’s Office and the Victorian Institute of Forensic Medicine. We expect to have a definite schedule of dates for the new program early next year.
We welcome Lisa Brodie to the administrative office and thank Danielle McLean for
Editor in Chief:
all her hard work with CLS for the past two years and wish her well at the Donor
Previous issues of the Coronial Communiqué have generated substantial discussion. In
Clinical Liaison Service
this edition we have replied to a query regarding the article “Too Busy to Keep Up-To-
Date?” September 2006: Volume 4, Issue 3. It is encouraging to receive comments and
questions about the cases. They should be addressed to our editor, Dr Adam O’Brien, and
+61 3 9684 4364
The cases we present in this edition highlight the importance of having reliable systems to support the safe use of medication and medical devices, and emphasise the
consequences of inadequate clinical handover of a patient’s care within and between
We’d like to take this opportunity to wish you all the best for the festive season and we
hope you all have a safe and happy new year.
basis. Subscription is free of charge and will be sent electronically to your preferred email address. If you would like to subscribe to CORONIAL COMMUNIQUÉ, please email us at: firstname.lastname@example.org
Next Edition: February 2007
The CLS team is keen to receive feedback
about this communication especially in relation to changes in clinical practice.
Please email your comments, questions and Case Precis Author: Carmel Young
suggestions to: email@example.com
resulted in him having limited vocabulary. It was noted by the coroner that
diarrhoea. He was assessed as being well
hours with advice to keep oral fluids up
overnight and return at 07:00 hours if he implications for his treatment”.
His mother took him back to the hospital HospITAL rEspoNsE
adopting guidelines for the treatment of
gastroenteritis from the Royal Children’s
to employ medical and nursing staff with
be admitted to the children’s ward for
and nursing staff be included in protocol
readily available and frequently audited.
when observations “exceed risky limits”.
39.3o centigrade, a heart rate of 200bpm,
in the children’s ward went to the ED to
complain about his condition but did not
contact the paediatrician. At 09:30 hours
design to ‘improve the flexibility of the
The second stent was initially too short
sheath and to increase the resistance to
and had to be removed and replaced with kinking’
, there had been no recall of the
report of adverse events of iliac rupture
patient had a cardiac arrest and failed to
treating surgeon’s belief that the ‘older’
the longer stent being of an older design
nature of this procedure the surgeon was This case raised a number of issues
large left haemothorax. Following advice
unable to confirm the device’s size prior
and the unavailability of ICU beds at any
further stated the belief that the older
patient and considered that the condition style of stents had been recalled by the
newer versions. Healthcare professionals
could be treated by endoluminal stenting manufacturer due to problems with
need to consider how much responsibility
via angiography. The patient’s condition
institutions, and the clinicians in ensuring
FINDINgs AND rECoMMENDATIoNs
that the most up to date equipment is
The Therapeutic Goods Administration
hence postulated: Average first 24h
A 3 hourly dose could therefore
be calculated by dividing this by 8. The
to be titrated to effect and the sedation
“[In the article] ‘Too busy to keep
up to date?’ the author proposes
Medicines Handbook. It is not clear in
the communiqué that this is intended
only for morphine parenteral doses for
opioid naive patients. I have had sites
approach us for this regimen that, as
far as I can see has little evidence to
support it. Your comments would be
effective use of patient-controlled analgesia by surgical patients.
requirements in the first 24 post-operative hours in patients older than
• The coroner had no doubt that having
• The difficulty in locating Ventolin,
Section, could not be located. The doctor
tried to locate obstetric Ventolin to slow
the delivery suite. The foetal heart rate
• A delay in seeking expert help. There
the cervix was fully dilated at 16:35hrs.
dilated. Her membranes were artificially
and appreciation of the gravity of J’s
respectively. He died four days later.
them took the drawn up pethidine to the resulted in severe hypoxic ischaemic
bedside. The syringe was put into a green encephalopathy.
practitioner before being administered.
significant risk of death associated with
on the table and was unable to be resuscitated. The cause of death was
oesophageal varices and hypersplenism. induced and given an epidural. After six next day and the anterior coronary
This was reported to the Coroner as the hours of labour the patient suddenly
collapsed due to an amniotic embolus and staff were unable to resuscitate
1368/04: An elderly male with AF, CCF, suicide attempt, hanged himself in his
Determination of caffeine in tea by HPLC Preparation of standard solutions You will require standard solutions of Caffeine in Methanol: Concentration Caffeine µ g / ml Mobile Phase Preparation of tea sample 1. Grind approximately 7g of the tea sample. Carry out the rest of the procedure in duplicate. +/- 0.001g of the sample in duplicate into a 500 ml round bottomed flask. 3.
Management of Nausea and Vomiting Nausea and vomiting may be caused by chemotherapy, radiation therapy, cancer, electrolyte imbalance, blocked intestines (including severe constipation) or other medications. It may prevent you from eating, drinking, and other daily activities and can lead to weight loss, dehydration, depression and fears about receiving more chemotherapy or radi