Case Number: 2019/337631
Date of Findings: 21 February 2025
Magistrate: Joan Baptie, Deputy State Coroner
CORONIAL LAW – Respiratory arrest, bronchial asthma, known sensitivity to non-steroidal anti-inflammatory drugs (NSAIDs), non-allergic hypersensitivity reaction, Tenterfield Hospital, absence of medical officer, lack of nurse accreditation in first line emergency care or advanced life support.
Responses
| Recommendations to |
Responses |
| NSW Health |
Awaiting |
| Hunter New England Local Health District |
Awaiting |
Recommendations
- That Ernestina Amarh-Ashitei is referred to the Health Care Complaints Commission/Nursing and Midwifery Board of Australia for investigation and review as to whether she engaged in unsatisfactory professional conduct in relation to her nursing care of David Scott Freeman on 27 October 2019, namely:
- her record keeping;
- the administration of aspirin after failing to inform Dr Ling of the disclosed allergy to ibuprofen; and
- the competency of her nursing skills.
To Hunter New England Local Health District
2. That the HNELHD rewrite and simplify the pro forma Tenterfield Hospital Business Continuity Plan so that there is a singular set of instructions (if possible, on a single page) providing clear, succinct and unambiguous escalation pathways for nursing sta to follow during a period of business continuity where there is no medical oicer on site at Tenterfield Hospital.
3. That the HNELHD review existing referral pathways and ensure that there are clear pathways for referral to respiratory and other specialists in the treatment of asthma for patients who present repeatedly to Emergency Departments with severe asthma exacerbation and are in receipt of multiple courses of prednisolone.
To NSW Health, in reltion to Chest Pain Pathway
4. That a copy of the findings be sent to NSW Health and that NSW Health consider the evidence of Professor Katelaris recommending amendment of the Chest Pain Pathway to include the following cautions;
CAUTION
- Does the patient have severe asthma?
- Does the patient have an aspirin/NSAID sensitivity?
To NSW Health, in relation to systemic issues of resourcing
5. A copy of these findings be sent to the NSW Minister for Regional health and to NSW Health.
