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 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: Adam O'Brien
all her hard work with CLS for the past two years and wish her well at the Donor Consultant Editor: Joe Ibrahim
Managing Editor: Zoe Davies
Designer: Caroline Rosenberg
Previous issues of the Coronial Communiqué have generated substantial discussion. In Address: 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 Telephone: +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: Next Edition: February 2007
The CLS team is keen to receive feedback about this communication especially in relation to changes in clinical practice.
CAsE NuMbEr: 730/04
Please email your comments, questions and Case Precis Author: Carmel Young suggestions to:
CoroNEr's CoMMENTs
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 CoroNEr's rECoMMENDATIoNs
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 CAsE NuMbEr: 3166/05
and had to be removed and replaced with kinking', there had been no recall of the report of adverse events of iliac rupture CLINICAL suMMAry
patient had a cardiac arrest and failed to CoroNIAL INvEsTIgATIoN
treating surgeon's belief that the 'older' the longer stent being of an older design EDITorIAL CoMMENT
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 - age. 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 CAsE NuMbEr: 2577/02
• The difficulty in locating Ventolin, CLINICAL suMMAry
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


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