Inquest into the death of Kenneth MAWBY

Contributing factors

• Failure to arrange timely post-operative follow-up appointments despite documenting plan at discharge
• Inadequate pre-operative informed consent regarding non-motor risks and potential behavioural changes
• Mood disorder and behavioural disturbances following DBS surgery (overstimulation)
• Failure to communicate behavioural risks to patient and family despite evidence of problems in hospital
• Poor communication between treating neurologist and patient/family
• Treating neurologist on leave during critical post-operative period with no backup care arranged
• Patient and family unable to contact treating neurologist; forced to seek alternative care
• Lack of system for ensuring follow-up appointments made and communicated before discharge
• Inadequate discharge planning and documentation
• Timing of psychiatric assessment consultation only one day before surgery rather than earlier in process

Coroner's recommendations

1. The Asia-Pacific Centre for Neuro-Modulation / St Andrew's War Memorial Hospital Model of Care Flow Chart should be amended so the treating neurologist (in consultation with neurosurgeon, neuropsychiatrist and DBS nurses) approves patient for discharge
2. The Model of Care Flow Chart should be amended to make DBS nurses responsible for ensuring prior to discharge that: specific follow-up appointments with nominated medical practitioners are made, specific information is given to patient and family about follow-up arrangements, and all necessary records are provided to those providing follow-up care
3. A discharge checklist should be developed by Neurosciences Queensland for use at St Andrew's War Memorial Hospital, to be completed by DBS nurses for each patient, to ensure all required discharge steps are attended to prior to discharge
4. Neurosciences Queensland and St Andrew's War Memorial Hospital should establish a system to ensure a copy of the completed checklist is provided to the hospital for inclusion in patient records
5. A contact card should be developed by Neurosciences Queensland for provision to DBS patients on discharge, setting out contact numbers for DBS nurses, neurologist, neurosurgeon, neuropsychiatrist and Medtronic, so patients and families know whom to contact in an emergency