Inquest into the death of Helen Frances Honey
Deceased
Helen Frances Honey
Demographics
70y, female
Date of death
2021-02-21
Finding date
2026-08-21
Cause of death
Ruptured abdominal aortic aneurysm
AI-generated summary
Ms Honey was a 70-year-old woman admitted involuntarily to a mental health facility with acute psychosis. Six days before her death, an 8cm abdominal aortic aneurysm (AAA) was discovered incidentally on imaging, with vascular surgery review scheduled for the following Monday. On Saturday evening, she deteriorated acutely with hypotension and altered consciousness. The Rapid Response Team appropriately transferred her to the Emergency Department, but ED staff did not assess her upon arrival, instead focusing on policy questions about patient responsibility. Critical delays ensued: no Emergency Department doctor assessed Ms Honey until over 2.5 hours after arrival, by which time her AAA had ruptured. The coroner found that immediate assessment and ED collaboration would likely have changed her treatment trajectory, though catastrophic outcome may have been inevitable. Key failures included inadequate communication, lack of electronic medical records, failure to visually assess a critically ill patient, policy taking precedence over clinical need, and poor RRT leadership and training.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Delay in diagnosis of AAA rupture
- Failure of Emergency Department staff to conduct assessment upon arrival of critically ill patient
- Inadequate clinical handover and communication between Rapid Response Team and Emergency Department
- Lack of electronic medical records preventing shared information between facilities
- Focus on policy over immediate patient care needs
- Lack of clear leadership and training within Rapid Response Team
- Inadequate clinical documentation at multiple stages
- Interdepartmental friction and communication breakdown between mental health and emergency medicine
Coroner's recommendations
- More intensive training be provided to all hospital staff at CMH and the HNELHD on the need for and importance of maintaining contemporaneous and comprehensive clinical documentation
- A leader be appointed to every RRT that convenes within any hospital in the HNELHD, with a clearly identified role and clearly delineated tasks, and focused training be provided to such team leaders
- The appointment of an RRT leader be based upon an assessment of the person within a given RRT who, based on his or her experience and skillset, is best placed to play a leadership role within that team
- The training provided to RRT members in the HNELHD be enhanced to ensure a greater emphasis on simulated emergency scenarios
- All staff in the Emergency Department be provided training that specifically focuses on the interplay between policies and the immediate needs of a particular patient and the ultimate responsibility to ensure the primacy of the latter in emergency contexts
- All staff in the Emergency Department be provided training that specifically focuses on the need to conduct an assessment of any patient that is brought by any RRT to that department, regardless of where that patient has been brought from
- All staff in the Emergency Department be provided training that highlights the differing experience levels of RRT members, and which highlights the need to assume that if an RRT brings a patient to the Emergency Department, that the patient requires emergency care
- Every effort should be made to put in place training and education programs aimed at promoting awareness of the significant consequences that may flow from a clinical environment where staff from different departments are not working together collaboratively and respectfully
- Training be provided to all RRT and Emergency Department personnel at CMH who are not involved in the day-to-day care of acute mental health patients, about the diagnostic challenges that such patients can present
Full text
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