Jessica Hilary Bovill died after errors were made during her treatment at the Canberra Hospital in 2020. Photo: Michelle Kroll.
CONTENT WARNING: This article contains information some may find distressing.
A “much-loved wife and mother” died due to the mistakes made at the Canberra Hospital during her treatment, a coroner has found.
Jessica Hilary Bovill, a 43-year-old mother of three, died at the hospital in 2020.
ACT Coroner Ken Archer said she started working at CSIRO in 2017, after which she received an injury that developed into chronic pain.
The coroner, who has published his findings from the inquest into her death, said her husband found her unconscious on 8 December 2020 after she had consumed a medication in overdose quantities.
Then during her treatment at the Canberra Hospital’s emergency department, she was “administered sodium bicarbonate in doses that were far in excess of therapeutic requirements”, he said.
As a result, she suffered injuries consistent with brain death.
“I find that an error in sodium bicarbonate dosage caused Jessica’s death,” Coroner Archer said.
“The reasonable survival prospects she had were lost because of the administration of sodium bicarbonate in excessive quantities.”
In his provisional findings, he made adverse comments about the ACT Government, and an emergency department specialist anonymised as ‘Dr TX’.
Dr TX was the clinician responsible for prescribing medications to Ms Bovill after she arrived at the hospital, including the sodium bicarbonate.
Coroner Archer said the hospital didn’t have an onsite toxicology service at the time of Ms Bovill’s death, but Dr TX did not consult a toxicology phone hotline that was available.
Dr TX gave directions to begin the infusion of sodium bicarbonate and then continued it later. After attending other tasks, she returned to find another doctor looking “very concerned” about Ms Bovill’s treatment.
“Up until that point, I had lost situational awareness of how much sodium bicarbonate had been administered, given the other issues I was addressing,” Dr TX said.
“My focus had been on ensuring we managed the acute and immediately life-threatening risk of cardiac instability.”
As Dr TX was distressed by her mistake, others took over caring for Ms Bovill.
The inquest investigated Jessica Bovill’s treatment at the Canberra Hospital. Photo: Michelle Kroll.
Staff tried to treat the medical issues she suffered as a result of the sodium bicarbonate, but she was declared brain dead on 11 December 2020.
“It is not clear from the evidence as to how much sodium bicarbonate was eventually administered and Dr TX was unable to say with certainty,” Coroner Archer said, adding there were discrepancies between two medical charts and the clinical notes.
Professor Olaf Drummer, a forensic pharmacologist and toxicologist, gave advice about the extent of the sodium bicarbonate overdose, estimating it could have been almost three times the maximum recommended dose.
“It is not possible to come up with a number of how many times her bicarbonate dose was exceeded given we don’t know what bicarbonate dose she needed; arguably she may not have needed much, if any,” he said.
Throughout the inquest, Ms Bovill’s husband argued she would have survived her medication overdose and that Dr TX’s negligence caused her death.
Coroner Archer found the doctor’s actions had contributed to her death.
The ACT Government accepted the criticisms made in Coroner Archer’s provisional findings, while a spokesperson from Canberra Health Services told Region the government acknowledged “the grief, loss and sadness the family have experienced following Ms Bovill’s passing and throughout the coronial process”.
The spokesperson said the government will consider the inquest’s findings and is legally required to respond.
“Canberra Health Services has already implemented a range of policy and practical changes in response to Ms Bovill’s death,” they said.
For instance, a new policy has been developed with a section that clearly outlines specific situations requiring discussion with the Poisons Information Centre and about documenting those discussions.
Also, changes have been made that restrict the availability of sodium bicarbonate and the mechanism for how and when it can be prescribed for treatment.
If you or someone you know needs help, you can contact:
Lifeline’s 24-hour crisis support line – 13 11 14
Suicide Call Back Service – 1300 659 467
Kids Helpline – 1800 551 800 or kidshelpline.com.au
MensLine Australia – 1300 789 978 or mensline.org.au.
