Inquest into the death of Mahmoud ALLAM

Contributing factors

• Facial skin infection with community-acquired MRSA colonisation
• Spread of infection to right cavernous sinus
• Bloodstream invasion by CA-MRSA
• Metastatic infections in lungs and epidural/prevertebral spaces
• Cavernous sinus thrombosis
• Inadequate vital sign observations on 15-16 June 2016
• Probable non-administration of flucloxacillin at 12:00am on 16 June 2016
• Poor documentation of treatment plans and observation requirements
• Delayed escalation to hospital

Coroner's recommendations

1. Justice Health review its training programs and material for clinical staff to ensure adequate measures are in place for detection, management, and prevention of CA-MRSA, including consideration of whether training recognises that CA-MRSA is likely more prevalent in correctional centres than other community settings, and whether Mahmoud Allam's death (with anonymization and family consent) should be used as a case study
2. Justice Health give consideration to whether it is necessary or desirable to develop a specific policy or guidelines concerning the prevention, detection and management of community-acquired methicillin-resistant Staphylococcus aureus
3. Justice Health give consideration to whether it is possible to conduct or commission research by analysing historical patient data and collecting future patient data (including appropriate social, economic and demographic data) to assist in determining the prevalence of CA-MRSA in correctional centres in New South Wales
4. Justice Health review its training programs for clinical staff to ensure they appropriately emphasise the importance of: properly documenting all aspects of a patient's treatment plan in the patient's health record; properly documenting the level/type and frequency of observation for patients placed in clinical observation beds; and giving timely and appropriate consideration to whether required medical care can be practically delivered in a correctional centre setting
5. Chief Executive Officer of Therapeutic Guidelines Limited refer the following issues to the antibiotic expert group preparing the next edition of Therapeutic Guidelines: Antibiotic: (a) whether there is proper epidemiological basis for developing treatment guidelines for cellulitis in the 'danger area' or 'danger zone' of the face; and (b) whether there is proper epidemiological basis for identifying residence in a correctional centre as a risk factor for patients with purulent cellulitis where Staphylococcus aureus is suspected
6. Chief Executive Officer of Therapeutic Guidelines Limited consider whether there is an appropriate way to address these issues prior to the next edition of Therapeutic Guidelines: Antibiotic, such as by establishment of a special or ad hoc working group