1. From Death We Learn 2009 Diabetic Keto-Acidosis causing death Office of Safety and Quality in Healthcare Reference: Halford Inquest April 2009

2. Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together 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

3. Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together 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

4. Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together 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

5. Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together 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.

6. Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together 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.

7. 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