Inquest into the death of Pauline KESSELL

Contributing factors

• prolonged endoscopic pyeloscopy procedure (108 minutes active laser time) on large 5cm infected staghorn calculus
• increased intrarenal pressure creating pyelovenous and pyelolymphatic backflow
• dissemination of Proteus mirabilis bacteria and endotoxins into bloodstream
• failure to use percutaneous nephrolithotomy for large stone despite international guidelines recommending it for stones >2cm
• failure to alert anaesthetist to heightened sepsis risk
• anaesthetist unable to leave operating theatre to review deteriorating post-operative patient
• delayed clinical review of patient in PACU despite nursing concerns from 19:55 onwards
• lack of clarity regarding responsibility for antibiotic administration
• failure to administer ceftriaxone in PACU
• delay in administering Tazocin (approximately 3 hours after ordering)
• no intra-operative communication between surgeon and anaesthetist

Coroner's recommendations

1. To the Urological Association of Australia and New Zealand: give consideration to the need for further guidance to urologists on treatment of large staghorn calculi
2. To Ramsay Health Care and Westmead Private Hospital: incorporate in proposed Lessons Learned procedure consideration of problems arising where multiple consultants attend a patient regarding clarity of responsibility for ensuring antibiotic administration
3. To Ramsay Health Care and Westmead Private Hospital: incorporate in Lessons Learned procedure consideration of methods, including use of stat charts, for ensuring antibiotics are given promptly upon ordering
4. To Ramsay Health Care and Westmead Private Hospital: incorporate in Lessons Learned procedure consideration of and dissemination of information about the dilemma facing experienced PACU nurses in securing clinical review for concerning patients, addressing both those making calls (PACU nurses) and those receiving calls (anaesthetists/VMOs and Rapid Response Team members)