Coroners Act In the matter of Coronial Findings and Recommendation into the Death of Mr Owen King pursuant to section 46B dated 3 December 2003
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Blood tests showed significantly fewer white blood cells than normal, and respiratory failure. That is, the oxygen in his blood was half normal. In addition he was developing acidosis. That is, his blood was becoming slightly acid because his oxygenation and circulation was not enough to allow normal metabolism. Dr Afilika told me about the patient. I noted he was looking exhausted, dry, and was labouring to breathe. I wrote an order for his initial antibiotics (penicillin and gentamicin) at 1745 so I would have seen him within a few minutes of that time. He was moved to the resuscitation area of the emergency department and given large amounts of intravenous fluids, antibiotics, and high flow oxygen. I called the intensive care/anaesthetic consultant who attended shortly thereafter and made arrangements for Mr King to go to the Intensive Care Unit following his initial resuscitation. Mr King appeared able to understand what was happening to him, although he was breathing too quickly and too exhausted to respond in sentences; he could manage yes or no. I do recall noting that although this patient was critically ill there was nothing to suggest previous poor health; he was well- nourished and muscular. Mr King responded poorly to resuscitative measures. He was given 8 litres of intravenous fluid but continued to have low blood pressure, and in spite of giving as near to 100% oxygen as we could manage we could not raise his oxygen to near normal limits. The Intensive Care consultant decided Mr King would need to be intubated, that is, go onto a ventilator or life support machine which could give 100% oxygen and take over the work of breathing for him. It was clear that Mr King was exhausted. Mr King, I believe, understood the explanation that was made to him at the time and agreed to this plan. The Intensive Care consultant next arranged to put in a central venous line. (This is a cannula, put in near the neck or shoulder; that goes to the vena cava which returns blood to the heart; measuring pressures here helps with fluid management). Such a cannula also allows inotropes to be given; these are drugs which stimulate the heart and help to maintain blood pressure. Mr Kings blood pressure was poor and there was a danger that it would drop further when he was on the ventilator. 14