managing sudden death in hospital

A great article in the BMJ detailed the role junior doctors play in the verification of sudden death in a hospital setting. The following extract identifies the decision making process that will assist a junior doctor faced with such a sudden death in the referral of that death to the coroner.

If the answer is yes to any of the following questions, then the death must be referred to the coroner. Discussion is usually with a coroner’s officer; the doctor must be clear about the reason for referral, and if uncertainties remain, the doctor should not be dissuaded from further discussion with the coroner in person.

 

Might injury have played a part?

 

Injury may have been inflicted by another person or by the deceased himself or herself, or it may have arisen as the consequence of an "accident," at home, at work, in the street, or in hospital.

The delayed complications of injury (such as pneumonia after fractured neck of femur, or pulmonary thromboembolism after surgical repair of any fractured bone) should be regarded as a consequence of injury.

It does not matter when the injury occurred—for example, septicaemia from urinary tract infection in a paraplegic patient after injury to the backbone should be referred to the coroner even if that original injury occurred decades before death. If the death is a consequence of injury it should be referred to the coroner. Scrutiny of all medical records is therefore essential when considering whether a death is to be referred.

 

Might any toxic substance be involved?

 

This includes any death that results from the immediate or delayed actions of any drug (including alcohol) or poison, regardless of whether the drug is therapeutic or recreational. The death may result from self poisoning, poisoning by someone else, and unintentionally or by intention. Fatal allergic reactions (for example, anaphylaxis) to therapeutic drugs are included so should be referred to the coroner.

 

Might there have been something unnatural causing or accelerating the death?

 

This possibility should be considered carefully when the death is wholly unexpected, albeit from natural causes, and when the possibility exists that someone (or some institution) may be blamed. For example, even if the cause of death is established, if there are allegations of poor or inappropriate treatment or inappropriate delay before treatment or diagnosis, the death should be referred to the coroner.

Any death that occurs during surgery or before the recovery from an anaesthetic should be referred to the coroner.

If the circumstances leading to death may be regarded as a serious untoward incident, not only must the coroner be informed, but the trust’s policy on such incidents must be triggered.

Any death from a disease contracted during the course of employment (in particular, pneumoconiosis) should be referred to the coroner.

 

Is there evidence that neglect by any person or institution has played a part?

 

Neglect may be on the part of the deceased person—for example, a person admitted with hypothermia. Alternatively, neglect may be on the part of a carer. For example, an elderly person might be admitted from a nursing home with multiple bed sores and poor nutrition without adequate explanation and may die in hospital while those conditions are being treated. This means that a lengthy interval may have elapsed between admission and death, and the patient may in fact have died from an illness unrelated to the sores and poor nutrition (for example, she might have died from a hospital acquired infection or a pulmonary embolus). It is therefore important to consider the complete history relating to the admission.

 

Was the deceased in custody at the time of admission or death?

 

If the person was admitted from prison to hospital the death should be referred to the coroner. If a death seems to arise from an incident after arrest, pursuit, or detention by police officers then that death should be referred to the coroner.

 

Is there no clinical history or evidence whatsoever that allows you to come to a decision as to cause of death?

 

Refer the death to the coroner.

 

Frost PJ, Leadbeatter S, Wise MP. Managing sudden death in hospital. BMJ 2010; 340:1024-1028