Inquest into the death of Paul Lau

Contributing factors

• prescribing error by anaesthetist - Fentanyl patch and Fentanyl PCA prescribed to wrong patient
• failure to detect prescribing error by pharmacy staff
• failure to detect prescribing error by nursing staff in recovery and ward
• failure of anaesthetist to recognise prescribing error during post-operative ward visit
• poor handover practices between recovery and ward staff
• inadequate opioid awareness among nursing staff
• failure to recognise danger of dual opioid delivery modes
• failure to escalate signs of patient deterioration
• inadequate patient observation by assistant in nursing
• TrakCare alert system - overriding alerts in batches without careful review
• lack of verification of patient identity in electronic prescribing
• lack of structured post-operative pain plan communication

Coroner's recommendations

1. Establish a working party comprising IT, Anaesthetics Department, Nursing directorate, Pharmacy and Patient Safety Manager to review lessons learned and implement reforms
2. Conduct staff seminars with Anaesthetics, Nursing and Pharmacy staff on missed opportunities in Paul Lau's case, addressing communication, handover, opioid policy, high-risk medication observation, Schedule 8 checks and responding to patient deterioration
3. Implement patient identity verification in TrakCare before submitting medication orders, including manual entry of patient name or urgent interim measures
4. Add 'current medications' or 'medications history' field to pre-anaesthetic assessment in TrakCare
5. Add 'post-operative pain plan' field to Recovery Progress Notes template in TrakCare
6. Investigate feasibility of alerts when medications added to patient chart after transfer to PACU/Recovery
7. Review TrakCare alert system: reduce alert numbers, remove default batch override, create alert hierarchy, implement distinct alert for duplicate prescribing, optimise alert presentation (font, format, sound, colour, placement)
8. Implement mandatory TrakCare proficiency assessment by independent person using simulations/scenarios for anaesthetists as part of medical practitioner accreditation
9. Conduct handover seminars with nursing and anaesthetics staff including simulations, feedback and mechanisms to enhance communication
10. Conduct regular audits of handover practices with priority to PACU/Recovery, publish results on hospital intranet
11. Review perioperative management including monitoring of high-risk medications, post-operative anaesthetist review in PACU/Recovery and ward, introduction of pain service, and alignment with relevant clinical guidelines