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Contributing factors

• Failure to perform timely Glenn shunt surgery
• Loss of follow-up due to poor coordination between cardiologist and surgeon
• Absence of written surgical plan or formal referral
• No backup appointment system for surgical follow-up
• Failure to monitor and report clinical deterioration to surgeon
• Lack of formal surgical waiting list
• Inadequate documentation and communication between specialists
• Cardiologist ceased reviews after referring to surgeon
• Surgeon assumed responsibility remained with cardiologist without explicit handover

Coroner's recommendations

1. A policy to ensure that all decisions concerning surgical and parasurgical procedures made during joint surgical review meetings are properly documented, included in the medical records of each patient the subject of discussion at such meetings and promptly communicated in writing to any relevant clinician missing from the meeting
2. A policy to ensure that should a treating clinician decide in a particular case to depart from a decision of the meeting, such change or changes be promptly communicated in writing to the Head of the Heart Centre or the Head of Cardiothoracic Surgery within the Heart Centre and a copy inserted in the patient's medical records
3. A policy to ensure that a referral by a cardiologist to a surgeon be accompanied, at the time the referral is made, by a letter of referral sent to the relevant surgeon with a copy to be placed in the medical records of the patient
4. A policy to ensure that a back up appointment for review by the treating cardiologist is made and documented whenever a cardiologist refers a patient to a surgeon or other clinician for surgical or parasurgical treatment
5. A policy to ensure that a referral by a cardiologist to a surgeon or other clinician for surgical or parasurgical treatment be accompanied by advice that the patient re-present to the cardiologist within a prescribed period, but not more than 6 months, in the event that such treatment does not occur within that time
6. A policy to ensure that the Head of Cardiothoracic Surgery within the Heart Centre compile and maintain a surgical waiting list or lists detailing all patients for whom surgery is planned or contemplated within 12 months