Inquest into the death of Shona Hookey

Contributing factors

• failure of disability support workers to escalate care despite hours of severe distress
• failure to call ambulance until late evening despite neurologist's advice
• incorrect triage category assignment (Category 3 instead of Category 2)
• prolonged wait on ambulance trolley (two hours) without adequate assessment or care
• failure to provide pain relief or fluids in ambulance bay
• failure to perform adequate physical examination
• anchoring bias on misleading history of foreign body ingestion
• inadequate assessment of vital signs
• failure to escalate case appropriately despite obvious distress and abnormal presentation
• apparent consideration of disability as factor in treatment decisions
• delayed resuscitation efforts
• emergency department overcrowding and resource strain
• poor contemporaneous record-keeping
• failure to recognise deterioration
• delay in calling Public Guardian unnecessarily

Coroner's recommendations

1. South Western Sydney Local Health District should review record-keeping practice and procedure in the Campbelltown Hospital Emergency Department to ensure contemporaneous clinical records are made by staff and staff are provided with means to do so with minimum of inconvenience. The coroner noted that notebooks, dictaphones and smart phones could be used with later transfer to electronic records to solve the practical problem of inconvenience of computer documentation during acute patient care.