Inquest into the death of Melissa King

Contributing factors

• Inadequate micronutrient replacement, particularly thiamine supplementation
• Gross fluid and sodium overload not appropriately managed
• Premature transfer from ICU/HDU to general ward despite clinical instability
• Persistent unexplained tachycardia with prolonged QT interval
• Altered MET calling criteria not communicated to receiving team
• Breakdown in communication between ICU, endocrinology, and gastroenterology teams
• Incomplete and unsigned transfer summary not provided to receiving ward
• Lack of verbal handover between ICU and ward teams
• Inadequate after-hours medical review on general ward
• Administration of glycoprep bowel preparation to oedematous patient
• Bilateral pleural effusions and pulmonary oedema
• Signs of fluid overload including anasarca and ascites
• Electrolyte and metabolic derangements not appropriately managed post-ICU transfer
• Low serum albumin not corrected
• No intensivist involvement in decision to discharge from ICU

Coroner's recommendations

1. Structured ICU/HDU to ward transfer guideline now implemented requiring: contact with receiving ward registrar, verbal nursing and clinical handover, core observations within 30 minutes of transfer, ward registrar review within 1 hour of arrival, and activation of clinical emergency response if review not completed within 1 hour
2. MET calling criteria alterations must be approved at consultant level, documented, reviewed every 72 hours, and communicated to receiving ward AMO and nursing staff
3. Decision to discharge from ICU must involve consultation with all treating teams, with disagreements escalated to consultant level or Director of Medical Services
4. Abolition of after-hours book system replaced with electronic handover and jobs list with automatic flagging for review
5. Additional staffing for intensive care including additional registrar for weekday evenings, additional critical care senior registrars for after-hours, and additional intensive care consultant
6. ICU registrars no longer called away for 'between the flags' reviews unless code blue
7. Transfer summary documentation to be completed and available electronically to receiving ward
8. Education and training on new protocols for all clinical staff with ongoing audit and compliance monitoring
9. Future funding sought for single integrated database to allow all staff access to ICU/HDU progress notes