Inquest into the death of Nicholas Wells

Contributing factors

• Inadequate management plan for suspected bowel perforation by Dr Kusyk
• Failure to escalate to surgical consultant despite suspicion of life-threatening injury
• Failure of Dr Kusyk to immediately consult with supervising consultant Dr Koshy
• Failure of Dr Koshy to personally review patient after 7pm handover discussion
• Poor communication regarding urgency between junior and senior doctors
• Inadequate frequency of clinical observations on surgical ward
• Inadequate nursing observations during one-to-one specialling care
• Misinterpretation of deterioration as drug withdrawal rather than surgical emergency
• Lack of formal notification to supervising consultant regarding IMG supervision requirements
• Inappropriate appointment of IMG requiring Level 1 supervision to registrar-level position

Coroner's recommendations

1. That Hunter New England Local Health District consider creating a policy document that reflects the current practice at John Hunter Hospital that no International Medical Graduate subject to Level 1 supervision be appointed to a position beyond that of an intern, and distribute this to the Director of Medical Workforce and to all selection panels constituted to employ junior medical staff
2. That the LHD consider creating a policy document specifying whether International Medical Graduates subject to different levels of supervision are eligible to be appointed to intern, resident or registrar positions within the LHD
3. That the LHD consider creating a policy framework to govern the way in which International Medical Graduates are supervised and monitored, including a system to ensure that their supervision requirements are communicated to the senior medical staff who provide their supervision
4. That the LHD consider undertaking a review of the Handbook and Guidelines for Junior Medical Staff and Trainees – John Hunter Hospital Surgical Services with a view to revising Section 8.3, 8.4 and 15.6
5. That the LHD consider revising Local Procedure JHH_0362 – Clinical Responsibilities of the Attending Medical Officer (AMO) so as to require that AMOs personally and fully assess patients within 24 hours of admission other than in exceptional circumstances
6. That the LHD consider providing training and education to medical staff at John Hunter Hospital in relation to the need to complete the Standard Adult General Observation Chart where a medical officer wishes to prescribe a specific frequency of observations
7. That the LHD consider including as part of its auditing of patient specialling whether the patient's respiratory rate has been documented 15 minutely and whether vital sign observations have been attended to at least every 30 minutes in cases where the patient requires specialling due to acute/deteriorating medical condition