Dear readers
Its been a while since I sat down and actually wrote an article but recently the publication of a coroners inquest finding in Northern Territory that I had been awaiting, triggered something in me. Its a topic that I have been studying, observing and trying to advocate for for the best part of a decade. After reading the tragic findings and seeing familiar and repeated things in the outcome, something stirred within me and now I feel compelled to try to lay it down on digital paper.
This blog the PHARM I started in 2012 when I was with the Royal Flying Doctor Service . I retired from that life in 2021 after 17 years on the aeromedical frontline. I am now semiretired rural doctor . During my PHARM career I found a great need to improve how we managed acute behavioural disturbance in remote Australia that would often require aeromedical transfer. Hence the beginning of my research path into this area and developing the idea of ketamine sedation for psychiatric aeromedical retrieval. The more I researched the more I uncovered about sedation related deaths in rural and regional hospitals, even prisons. These were all a matter of public record as coronial findings. Compelled to try to speak out about this safety issue I wrote and published in conjunction with several like minded colleagues the Surviving Sedation guidelines on the PHARM website in 2015. This has been updated several times with new references over the ensuing years. 11yrs on, the release of the coronial finding into the most recent sedation related death in Alice Springs hospital in 2023, made me pause and reflect upon a startling yet inescapable conclusion : we have learnt nothing from these deaths. No matter the number of coroners’ recommendations into improving processes etctetc, it is my conclusion that like other things related to patient safety in Medicine, we simply cannot learn from them. Why not? Maybe its inherent human error, just too many holes in the swiss cheese of patient safety. But should we stop trying in this Sisyphean task?
I for one will not stop trying , even after I retire from medicine, because I know now, these deaths, these preventable deaths will keep happening. There is no mystery serial Zodiac killer here. We are the problem and that yes is a tragedy
Here is the most recent case, the tragic sedation death of
KUMANJAYI BROGUS UNGWANAKA
ON: 22 NOVEMBER 2023
AT: ALICE SPRINGS HOSPITAL
This woman was given injections of droperidol and midazolam in a mental health unit then placed on a mattress on the floor in front of the nursing desk with no oxygen saturations monitoring and simply visually observed as she went into acute respiratory failure and died.
Compare this to the first sedation death I studied of David Lee in remote Western Australia. The full finding was taken off line for years but recently has been re-released as archival publication here
The 2 sedation cases are 16 years apart , one in NT , the other in WA . Yet they bear striking similarities. Both persons deceased had schizophrenia. Both died of respiratory depression from midazolam and antipsychotic sedative administration. Both were admitted to hospital.
For readers of the PHARM you know I have documented other sedation deaths over the last 10+ years. All have striking similarities.
- Respiratory depression
- Midazolam
- lack of adequate clinical handover
- lack of adequate sedation monitoring
- Use of injection sedatives
There remains no national standardised guideline nor training module in sedation for acute behavioural disturbance.
We can do better, we must do better. Everyone does their own thing but doesnt see the bigger picture. This is hospital medicine at its worst. I thought that with getting ketamine implemented as a safe alternative the intubation and ventilation for psychiatric aeromedical retrieval then things would improve safety wise. Its clear now to me that the transport and retrieval phase of the care for someone with an acute behavioural disturbance in remote Australia is no longer the main safety issue. Folks are now dying from sedation in the actual hospitals that they see as places of safety and care. Sedation on the PHARM paradoxically is now safer than in hospitals with 4 walls and airconditioning.
regards
Ketaminh
