Inquest into the death of Lennie Pinawrut

Contributing factors

• failure to communicate rising creatinine levels to treating surgeon
• inadequate ultrasound request specification ('post void' not included)
• misinterpretation of ultrasound findings as successful voiding rather than anuria
• failure to involve renal team despite deteriorating renal function
• inadequate discharge planning with no escort arranged
• premature discharge without written discharge summary
• failure to consider dementia and cross-cultural communication needs in discharge decision
• patient sent home by bus alone in hospital pyjamas without notification to family
• delayed preparation and circulation of medical discharge summary (18 days post-discharge)
• excessive junior medical staff workload and lack of technological support

Coroner's recommendations

1. RDH to continue reviewing and enhancing admission and discharge procedures, including implementation of procedures for admission under multiple medical teams
2. Implement technological fail-safe systems to support discharge planning in the absence of reliance on human communication alone
3. Introduce procedures ensuring all patients with moderate to advanced chronic renal insufficiency are notified to and reviewed by the renal team prior to discharge
4. Require medical personnel to order patient discharges in writing in patient records with clear specification of all post-discharge care
5. RDH to implement procedures facilitating timely completion and circulation of medical discharge summaries to relevant medical organisations