Coroner's Finding: Vanessa Ann Anderson

Contributing factors

• Failure to administer ordered anticonvulsant (Dilantin) despite consultant direction
• Multiple opioid analgesics (Endone and Panadeine Forte) prescribed without coordination or consultation between teams
• Anaesthetic registrar increased opioid doses without consulting neurosurgical team
• Inadequate neurological observations and monitoring
• Poor communication between junior doctors and consultant neurosurgeon
• Inadequate documentation and record-keeping
• Inadequate supervision of inexperienced staff (first-time ward in-charge, first-day intern)
• Staffing shortages (neurosurgery registrars attending training seminar)
• Absence of hospital-wide pain management guidelines
• Patient positioned away from nurses station
• Parental concern regarding Dilantin not further investigated or escalated
• Failure to recognize and appropriately escalate patient deterioration at 1am

Coroner's recommendations

1. Adolescent head injury patients to be nursed as close as possible to nurses station
2. Policy for nursing staff on importance of performing routine neurological observations at scheduled intervals
3. Development of 'Guidelines for Notifying a Consultant' directed to junior medical officers
4. Addition of tutorial to junior medical officer orientation regarding consultation with consultants
5. Development of acute pain management policy for neurosurgery department establishing that decisions on analgesia outside guidelines can only be made by registrar or consultant
6. Further in-house education for medical and nursing staff on pain management, opioid prescribing, and pain assessment
7. Distribution of patient brochure 'Analgesia in Neurosurgical Setting – Headache'
8. Continuing education on proper documentation in medical records and fluid balance charts
9. Implementation of system for periods of reduced registrar coverage due to training/educational requirements
10. Dissemination of Department of Health 'Guidelines for the administration of analgesia and the use of anti-convulsant therapy in the treatment of mild closed head injury' (December 2007) to all NSW area health services