Inquest into the death of D H

Contributing factors

• Failure to conduct adequate pre-operative anaesthetic assessment
• Failure to identify implanted cardiac defibrillator despite documentation in medical records
• Inappropriate choice of anaesthetic technique (laryngeal mask with total intravenous propofol) for high-risk patient
• Inadequate intra-operative monitoring of blood pressure
• Failure to recognise severe hypoxia, severe bradycardia, and pre-arrest signs
• Slow response to patient deterioration during procedure
• Absence of consultant anaesthetist review prior to surgery
• Pre-operative review conducted in anaesthetic bay immediately before surgery rather than in advance
• Loss of contemporaneous anaesthetic machine printouts

Coroner's recommendations

1. No specific recommendation made regarding out-patient diabetes and wound care services, as the coroner was satisfied that Dubbo Health Service had demonstrated clear understanding of need and that additional funding and multi-skilled team structures were now in place (including new High Risk Foot Clinic opened September 2018, Outreach Podiatry Clinic, and Marathon Health services).
2. Pre-operative anaesthetic review procedures have been adequately addressed by introduction of Pre Anaesthetic Assessment Protocol (April 2017), mandatory consultant review of high-risk patients (ASA 4–5), shift from bay-side reviews to formal pre-operative assessment, electronic medical records integration, and 'Speaking up for Safety' cultural safety training for all staff.
3. Hospital procedures for securing anaesthetic machine records have been adequately addressed by assignment of responsibility to anaesthetist, anaesthetic nurse, and recovery nurse; requirement that record be printed and placed on file before theatre discharge; prohibition on resetting machine until record secured; and investigation of data retention on hard drive systems.
4. Regarding Aboriginal Health Practitioners: while the coroner acknowledged the family's wish for additional AHP coverage, found no finding could be made that lack of weekend AHP availability impacted cause and manner of death. The coroner considered appropriate the Health Service's current strategy of recruiting more aboriginal staff overall (targeting increase from 4% to 7% of workforce) while continuing to fill newly created AHP positions, combined with mandatory cultural awareness training ('Respecting the Difference') for all staff.