From Death We Learn 2009 Diabetic Keto-Acidosis causing death Office of Safety and Quality in Healthcare Reference: Halford Inquest April 2009
The case Background • A rural university student became unwell over 48 hours • Symptoms of vomiting and lethargy. • PMHx of a rare autoimmune condition
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
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
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.
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.
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