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From Death We Learn 2009
Diabetic Keto-Acidosis causing death
Office of Safety and Quality in Healthcare
Reference: Halford Inquest
April 2009
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Office of Safety and Quality in Healthcare
The case
Background
• A rural university student became unwell over 48 hours
• Symptoms of vomiting and lethargy.
• PMHx of a rare autoimmune condition
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Office of Safety and Quality in Healthcare
The case
Management
The patient:
• Was seen 3 times in a general practice setting
• Did not have her urine tested
• Was treated for gastroenteritis & food poisoning
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Office of Safety and Quality in Healthcare
The case
Outcome
The patient:
• Had a a cardio-respiratory arrest at home
• Was taken by priority 1 ambulance to an Emergency Department
• Had a diagnosis of Diabetic Keto-acidosis (DKA) made during resuscitation
• Did not respond to advanced resuscitation
• Died in the Intensive Care Unit
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Office of Safety and Quality in Healthcare
The inquest
A coronial inquest revealed:
• The diagnosis of DKA was missed in the general practice setting.
– given the circumstances this was not unreasonable.
• Perceptions that people wait a long time in Emergency Departments may have influenced the patient’s and the family’s decision not to access hospital care directly.
• Early presentation to an Emergency Department would most likely have enabled the diagnosis of Diabetic Keto-Acidosis & prevented her death.
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Office of Safety and Quality in Healthcare
Key Question
The Deputy State Coroner recommended that General Practitioners should:
• try to elevate awareness of sudden onset Diabetic Keto-Acidosis in young people. (Royal Australian College of General Practitioners)
• not overlook the utility of urinalysis as a means of assessing both dehydration and the presence of Diabetic Keto-Acidosis.
• understand and educate patients about the functions of the Emergency Department to prioritise care and provide access to specialist support.
• consider that one rare autoimmune condition may indicate a propensity to another.
Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together
Office of Safety and Quality in Healthcare
Key messages
Diabetic Keto-Acidosis is a preventable cause of death in young people.
Urinalysis is a very useful bedside test in acutely unwell patients for assessing both:
Dehydration
the presence of Diabetic Keto-Acidosis
Perceptions about waiting times in Emergency Departments should not influence decisions to send acutely unwell patients to hospital