Inquest into the death of Sandra Cree

Contributing factors

• Delayed diagnosis at Lightning Ridge Multi-Purpose Service
• Failure to access prior medical records due to password protection
• Inadequate attempts to contact referring surgeon at St Andrews
• State Retrieval Consultant failed to communicate likely diagnosis to treating team
• Retrieving doctor prioritized sepsis over aneurysm rupture
• Inadequate FAST ultrasound technique with over-reliance on negative result
• Lack of formal handover between consecutive State Retrieval Consultants
• Failure to pre-alert receiving hospital of suspected diagnosis
• Patient's clinical presentation consistent with retroperitoneal hemorrhage rather than intraperitoneal

Coroner's recommendations

1. Development of written procedure by RaRMS for provision of laptop passwords to GPs/VMOs at Lightning Ridge Multi-Purpose Service and other facilities
2. WNSWLHD clinicians directed to make all reasonable efforts to contact hospitals where patients had recent surgery to obtain full clinical details
3. WNSWLHD clinicians directed to comprehensively document in pre-arrival notes all information provided by transferring hospitals regarding patient history and suspected diagnosis
4. Aeromedical Control Centre prepare written policy requiring State Retrieval Consultant to take full handover from referring clinician responsible for patient care
5. Aeromedical Control Centre provide express written guidance requiring State Retrieval Consultants to inform senior clinicians of preferred and secondary diagnoses and appropriate transfer destination as soon as formed
6. Revision of Aeromedical Control Centre policy documentation to clearly identify which officers bear ultimate responsibility for clinical management and transfer destination decisions
7. Express definition in Aeromedical Control Centre policy of what 'active input' means for State Retrieval Consultants in medical retrievals
8. Comprehensive training for all Aeromedical Control Centre staff on current and revised policy documentation
9. Written policy requiring formal Consultant-to-Consultant handover at State Retrieval Consultant shift changes with comprehensive training
10. Aeromedical Control Centre inform RFDS of NSW Ambulance protocols regarding permissive hypotension in medical retrieval settings for ruptured aneurysm
11. Royal Flying Doctor Service provide explicit written guidance to clinicians on potential use of permissive hypotension in medical retrieval settings for ruptured aneurysm
12. Aeromedical Control Centre introduce express written policy requiring handover from ACC to receiving hospital in all medical retrievals
13. WNSWLHD policy directive requiring receiving clinicians to review Patient Transfer Form and electronic notes from referring hospitals for critically ill patients