Eric Thompson

Identity and status

Coronial concern

An abnormal potassium result was telephoned to the emergency department and was available electronically, but it was not initially documented, escalated or acted upon. The coroner identified the absence of an efficient electronic method for the laboratory to deliver an abnormal-result alert; the workflow instead relied on person-to-person discussion and later escalation.

Respondent account

No respondent account is used in this case profile. The summary is limited to the primary Judiciary report and the review's transparent coding.

Reviewer-coded mechanism

The review codes this as a distinction between information being available and being delivered to accountable clinical work. These are reviewer classifications:

• LOOP: no reliable acknowledgement, escalation and closure chain was demonstrated.
• ALERT and VIS: electronic availability did not create an effective abnormal-result alert.
• RES: telephone retry introduced a fragile fallback dependency.
• GOV: the concern required an organisation-level delivery control.

Limitations

This is one investigation. It does not establish that electronic alerting alone would have prevented the death or define a universally appropriate alert design. The relative contribution of staffing, documentation, escalation and technical delivery cannot be separated from the report alone.

Defence applicability

The available-versus-delivered distinction is directly useful for fixed, deployed and remotely supported diagnostic services, particularly when recipients are absent or connectivity is delayed. It informs REQ-004 critical-result delivery, REQ-005 task routing and REQ-009 decision support. It does not establish Defence workflow performance.

Source documents

• SRC-019: Eric Thompson PFD, Judiciary

Last verified

14 July 2026. Primary Judiciary report checked and the distinction between availability and accountable delivery reconciled to CLM-008.