Inquest into the death of Colin Parker

Contributing factors

• Delayed identification of intracranial pathology (29 hours)
• Inadequate history taking in emergency department regarding syncope episode and head injury
• Inadequate clinical handover between cardiologists
• Delayed CT brain scanning relative to symptom onset
• Suboptimal anticoagulation reversal (delayed administration of protamine and fresh frozen plasma)
• Intubation delayed until GCS dropped to 9
• Mannitol not administered at Campbelltown Hospital
• Inexperience of junior medical staff in managing neurosurgical emergency
• Difficulties in arranging urgent inter-facility transfer
• Lack of consultant-to-consultant communication for time-critical transfer
• Lack of direct supervision of junior medical staff by consultant
• Administrative delays in bed allocation and retrieval service arrangement
• Insufficient escalation of transfer impediments to senior management

Coroner's recommendations

1. Provide targeted education and training to all nursing and medical staff regarding NSW Ministry of Health policy directive Clinical Handover – Standard Key Principles (PD2009_060)
2. Amend Patient Transfer: Inter-Facility Patient Transfer (SWSLHD_PD2015_004) policy directive to require mandatory (rather than preferred) consultant-to-consultant referral where consultants are immediately available for time-critical transfers; where consultants not immediately available, clause 4.7 should be followed
3. Amend Patient Transfer: Inter-Facility Patient Transfer (SWSLHD_PD2015_004) policy directive to replace 'Attending Medical Officer' and acronym 'AMO' with term 'consultant'
4. Amend Patient Transfer: Inter-Facility Patient Transfer (SWSLHD_PD2015_004) policy directive to require that in all cases of time-critical inter-facility transfers, consultants should provide direct supervision and support (whether by phone or in person) to junior medical staff involved in transfer process
5. Amend Patient Transfer: Inter-Facility Patient Transfer (SWSLHD_PD2015_004) policy directive to require that in all cases of inter-facility transfers, all written documentation relating to medication prescribed and administered is immediately available at receiving facility
6. Forward copy of findings to NSW Minister for Health with transcript of evidence of Dr P. regarding inter-facility transfer patient categories and timeframes
7. Recommend to NSW Minister for Health consideration of creating additional patient category requiring immediate transfer to preserve life, and review whether removal of nominated timeframes for time-critical and urgent transfers would improve timeliness and effectiveness of inter-facility transfer process