Inquest Into The Death Of Nathan Thomas James Wrench

Contributing factors

• failure to act on critical urinalysis results indicating dehydration
• failure to review nursing notes and fluid balance chart
• communication breakdown between nursing staff and doctor regarding test results
• delayed transfer to tertiary centre
• inadequate exploration of differential diagnosis including bowel obstruction
• failure to communicate with referring GP regarding clinical concerns
• over-reliance on verbal nursing updates without documentation review
• system pressures on visiting medical officer managing 24-hour shift

Coroner's recommendations

1. The ACT Attorney General and Minister for Justice should draw attention of NSW Minister for Health to facts of this case with a view to suggesting that the NSW Minister for Health: (1) Give consideration to the appointment of resident medical staff at Queanbeyan Hospital; (2) Re-examine in the meantime the requirement that local general practitioners accept responsibility for the care of patients at Queanbeyan Hospital on a 24-hour basis each 10 days; (3) Consider promulgating firm guidelines for the transfer of patients from Queanbeyan Hospital to The Canberra Hospital; (4) Consider directing that all paediatric patients presenting to Queanbeyan Hospital be referred forthwith to the specialist paediatric unit at The Canberra Hospital; (5) Consider whether evidence regarding Dr L.'s part in events warrants referral to appropriate NSW authorities