No recommendations for NT Health after Top End mum Janelle’s fatal cardiac arrest

The death in care of a Top End mum found wandering a remote community naked was ‘unavoidable’, the coroner has found.

The absence of a Cardiothoracic Surgery service at RDH meant that nothing could be done to save a 35-year-old Top End mum. Picture: Che Chorley

A coroner has made no recommendations after a Top End mum’s heart was squeezed out by a blood clot over hours while she waited more than 3000km away from a potentially life-saving surgery.

Coroner Elisabeth Armitage released her findings on Wednesday following the two-day inquiry into the death in care of a 35-year-old Aboriginal woman, who her family asked to be referred to as Janelle.

The mother-of-two passed away from a rare heart condition in Royal Darwin Hospital, after being admitted as an involuntary mental health patient that same day.

Ms Armitage found that despite the best efforts and appropriate care by medical staff “at every stage of her treatment”, nothing could have been done to save her life “as there is no on-site Cardiothoracic Surgery service at RDH”.

“It is tragic and regrettable that a 35-year-old woman who had none of the risk factors usually seen in a person suffering from an aortic dissection, passed away unexpectedly from such a rare condition,” she said.

“Her death was unavoidable.”

Territory Coroner Elisabeth Armitage found that despite the best efforts and appropriate care by medical staff “at every stage of her treatment”, nothing could have been done to save Janelle. Picture: Glenn Campbell

The coroner found that Janelle had been admitted to the acute mental health Cowdy Ward four times since 2006, when the then 20-year-old was diagnosed with schizoaffective disorder with a secondary diagnosis of bipolar.

Ms Armitage said she was up to date with her monthly depot injections medication when she started acting “agitated” on the morning of July 3, 2021.

Janelle was staying with family at the Weemol community, 300km from Katherine, when the Bulman Community Health Clinic started receiving calls that the 35-year-old was walking around town naked, yelling and throwing rocks at family members.

Clinic staff told the coroner Janelle appeared to be dehydrated and dirty, and she told them she was hearing loud noises and did not want her family around “judging her”.

Within 35 minutes of arriving at the clinic, District Medical Officer Jill Farrer recommended she be involuntarily admitted to RDH.

It was at the clinic where they first noticed the 35-year-old’s unusual vital signs, with a fast respiratory rate and low blood pressure.

Dr Farrer did note that part of Janelle’s symptoms were atypical for psychosis, including her difficulty standing, vomiting, and her refusal to allow a physical examination or oral medication.

The coroner heard Janelle told the on-board CareFlight doctor that she had a sharp chest pain, who flagged her concerns with the emergency department.

File photographs of Royal Darwin Hospital RDH. Picture: Che Chorley

Janelle told emergency department medical officers that the sharp pain in her chest began that morning, while she was feeding her son.

For nearly seven hours emergency staff tried to diagnose the suspected heart condition, while the mentally unwell woman remained in an “agitated” condition.

Just before 11pm, the 35-year-old told the Night Medical Registrar that her pain was “much better”.

Soon after a Code Blue was declared. Janelle was found pulseless and apnoeic.

A echocardiogram revealed clotted blood was building up and squeezing her heart.

Ms Armitage said doctors made a “last resort” thoracotomy — cuts made between ribs to reach organs in the chest — to manually remove the blood clot around her heart.

Ms Armitage said medical staff “exhausted all options to save her life” and Janelle was declared deceased two minutes before midnight.

An autopsy later confirmed the cause of death was aortic dissection, potentially possibly due to a bacterial infection.

Royal Darwin Hospital and Palmerston Regional Hospital Emergency and Trauma Centre director Dr Didier Palmer. Picture: Floss Adams.

Emergency Medical Consultant Nicolas Forget said that in almost 20 years of emergency medicine, Janelle was the first case he had seen of a young woman with an aortic dissection.

Emergency and Trauma Centre director Associate Professor Didier Palmer also concluded it was not a “missed diagnosis”, with rare conditions often an “elusive” diagnostic puzzle.

“Complex condition diagnosis is akin to peeling an onion one layer at a time,” Dr Palmer said.

“You sequentially exclude the likely diagnoses … and then progress to exclude less likely conditions.”

He said if Janelle’s condition was picked up earlier, and if a 24-hour on site cardiothoracic service was available, her mortality risk would have been about 20 per cent.

“The absence of a Cardiothoracic Surgery service at RDH meant that nothing could be done to save her in Darwin and she would have passed away before any transfer to Adelaide was achievable,” Ms Armitage concluded.

Originally published as No recommendations for NT Health after Top End mum Janelle’s fatal cardiac arrest