Inquest into the death of Eve Brown

Contributing factors

• failure to identify and document differential diagnoses
• failure to arrange CT imaging to exclude serious conditions
• failure to transfer patient to facility with imaging and surgical capability despite clinical indicators
• lack of vital signs monitoring for 12 hours despite yellow-zone temperature
• failure of on-call doctor to attend patient in person despite nurse contact
• inadequate nurse-doctor communication and lack of assertiveness in requesting physician attendance
• single nurse covering acute ward and emergency department overnight
• no specialist consultation before admission decision
• resource limitations at small rural hospital
• inadequate escalation and monitoring protocols

Coroner's recommendations

1. WNSWLHD review adequacy of practices and procedures regarding instruction to VMOs to consult experienced clinician (VRGS, vCare or other means) before admitting patient to small hospital facility like LRC, including discussion of diagnostic work-up and appropriateness of potential transfer to larger hospital, particularly for patients with suspected bacterial infection presenting with symptoms of infection but otherwise stable
2. WNSWLHD review adequacy of practices and procedures regarding random clinical reviews of VMOs' decisions around admitting acute patients to small hospitals rather than transfer to larger hospital, with reviews by clinicians with significant experience in generalist medical care in regional areas and specialist emergency/intensivist experience, to guard against lesser diagnostic standards at smaller facilities
3. WNSWLHD consider using Eve's case as part of scenario training for nursing and VMOs around identifying patients at risk of deterioration, transfer, and importance of consultation and discussions before admitting a patient
4. WNSWLHD review practices and procedures to ensure (i) frequency of vital sign observations being recorded is regularly audited and (ii) nursing staff independent of VMOs, if frequency of vital signs and patient monitoring in Emergency Department or acute admission is not undertaken consistently, immediately escalate to Nursing Unit Manager/Health Services Manager for action including consideration of whether transfer of patient with suspected infection should occur given capacity issues
5. WNSWLHD review adequacy of instruction to nursing staff regarding (a) duty of nurses in smaller regional hospitals without on-site overnight medical officers to request VMO attendance to examine patient if nurse considers appropriate, and (b) importance of nurses entering progress notes into electronic record system as contemporaneous to events as is reasonably practicable rather than single entry at end of shift