Inquest into death of THEADORA ZAAL

Contributing factors

• unrecognised or inadequately assessed aortic stenosis pre-operatively
• likely unrecognised adrenal insufficiency contributing to refractory hypotension
• delay in defibrillation during resuscitation
• inadequate staff familiarity with defibrillator equipment
• failures to activate MET calls despite meeting Modified Early Warning Score criteria
• insufficient medical coverage on wards during peak surgical times
• inadequate pre-operative cardiac assessment despite abnormal ECG and cardiac murmur

Coroner's recommendations

1. Calvary John James Hospital should implement training and changes to procedures such that where discretion is exercised to not make a MET call that is otherwise warranted by Modified Early Warning Score criteria, the exercise of that discretion and the reasons behind it should be formally recorded in patient progress notes
2. Calvary John James Hospital should undertake as a matter of priority an audit of its central cardiac monitoring systems and defibrillators to ensure they are all operating correctly and that there is no discrepancy between rhythms detected on each machine when used on patients
3. Calvary John James Hospital should undertake refresher training of staff as to the importance of keeping accurate records, specifically the need to properly scribe resuscitation efforts
4. Calvary John James Hospital should consider rostering two RMOs on duty to deal with emergencies during peak surgery times when many VMOs and other doctors will be in surgery on other cases