Inquest into the death of Robert Bischard

Contributing factors

• failure to postpone surgery despite acute kidney injury evidenced by creatinine 346 umol/L
• absence of pre-operative physician-led assessment for high-risk surgical candidate
• poor communication between Temora Base Hospital and surgical team regarding recent admission and elevated white cell count
• lack of structured perioperative acute shared care model
• failure to recognise critically low post-operative urine output (3ml) and escalate appropriately
• inappropriate continuation of diuretics (Lasix/furosemide) and anti-hypertensive medications (Irbesartan) post-operatively
• haphazard and incomplete fluid balance charting throughout admission
• failure to perform postural blood pressure measurements as requested
• inadequate senior medical oversight and delayed physician response on evening of deterioration
• poor inter-hospital communication regarding recent acute kidney injury episode

Coroner's recommendations

1. That the Murrumbidgee Local Health District give consideration to establishing a structured peri-operative acute shared care model or pathway targeted at identifying and managing risks during surgical admissions in patients with significant co-morbidities
2. That the Murrumbidgee Local Health District audit the use of daily fluid balance charts, the standard clinical pathway for a total knee replacement, and nursing compliance with medical requests for the completion of additional observations (such as postural blood pressure readings) on the Orthopaedic Inpatient Unit
3. That the Murrumbidgee Local Health District conduct further case presentations with staff (targeting nursing, medical and surgical staff) using Mr Bischard's case as an anonymised case study to prompt discussion around: (a) the need to carefully chart routine medications and allergies; (b) adequate completion of daily fluid balance charts and the standard clinical pathway for total knee replacement; (c) recognising 'low urine output persistent for 8 hours' as a red zone criteria under the NSW Health Between the Flags protocol; (d) the need for post-operative plans to be documented in the medical record in a timely fashion and for nurses to implement plans for additional observations where requested