Inquest into the death of Michelle McILQUHAM

Contributing factors

• failure to consider meningitis in differential diagnosis
• premature closure cognitive error
• lack of senior doctor assessment before discharge
• no investigations ordered despite seizure history and low GCS
• misinterpretation of signs and symptoms as behavioural rather than infectious
• failure to escalate concerns raised by nursing staff and mother
• inadequate documentation of nursing concerns and requests for review
• discharge while patient remained in pain and required physical assistance
• no last observations taken before discharge
• assumptions about behaviour related to developmental disability

Coroner's recommendations

1. Nursing assessment of specific high-risk patients triaged categories 1, 2, 3 before physical discharge from ED if no assessment within 30 minutes of last review while patient remains in ED
2. Nursing assessment of any patient requiring physical assistance to leave ED on discharge, unless doctor assessed this need at time of discharge decision; alternatively, amend discharge protocols with warning that such patients should not be discharged without doctor assessment of assistance need
3. All patients presenting with first-ever seizure should be assessed by senior doctor in ED within 30 minutes; if unable, FBC and standard battery of tests should be ordered
4. All patients with GCS less than 15 should have GCS assessed on admission and prior to discharge
5. All patients triaged categories 1, 2, 3 with developmental disability should be assessed by senior doctor before discharge
6. Annual education of all ED clinical staff on detection of signs and symptoms of sepsis, including appropriate investigations and management with rapid IV antibiotics, fluids and source control
7. Junior medical officer's differential diagnosis should be documented in patient's clinical record, ideally in the Presentation Plan
8. Review Section 1 of Bankstown Hospital Emergency Department Supervision Guideline in accordance with these findings
9. Include in ED staff in-house training regular session on mental and physical preparation for shifts and self-care during shifts
10. Emphasise to Nursing Unit Managers and senior doctors that staff efficiency is improved by attention to self-care, especially rehydration during shifts
11. Develop poster or notice in ED warning staff of effects of fatigue and urging regular rehydration and light meals during shifts