Inquest into the death of Katrina McGrady

Contributing factors

• Failure to escalate increasing severity of headaches (5-8/10) from nursing staff to Dr E. between 30 August and 4 September 2020
• Failure to obtain repeat imaging (CT or MRI) despite escalating headaches and symptoms suggestive of possible minor leak or aneurysm growth
• COVID-19 pandemic protocols that separated neurosurgical teams and disrupted multidisciplinary team meetings and communication
• Inadequate informed consent process regarding treatment options before commencing antiplatelet dual therapy
• Insufficient documentation of discussions between specialist medical staff regarding treatment planning
• Communication with First Nations family regarding brain death certification and withdrawal of vasopressin not compliant with hospital policy regarding cultural sensitivity
• Inadequate pre-operative discussion with patient about alternative treatment modalities (craniotomy versus endovascular flow diversion)

Coroner's recommendations

1. HNELHD to consider whether the practice of obtaining informed consent is appropriately adhered to within its surgical units, specifically regarding commencement of medication required for a specific procedure where all treatment options have not been sufficiently explored with or communicated to the patient, and whether commenced medication may be counter to other treatment options
2. HNELHD to review its Comprehensive Care: Adult Inpatient Multidisciplinary Care Plan to determine whether it is appropriate and fit for purpose for each neurosurgical team or unit, and whether it has been sufficiently rolled out to John Hunter Hospital
3. HNELHD to recommend to John Hunter Hospital that it review its practices of raising end of life and organ donation with First Nations families to ensure a discussion of the clinical team occurs as a first step, wherever possible, prior to the issue being raised with the family