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.

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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