Inquest into the death of Sara Lorraine Hampel

Contributing factors

• Absence of sepsis recognition protocol at Gove Hospital and Royal Darwin Hospital
• Delayed diagnosis of sepsis due to atypical presentation (no fever, leg pain rather than perineal focus)
• Failure to escalate to senior consultant with relevant expertise
• Junior registrar (Dr R.) unable to manage complex case requiring senior infectious diseases physician
• Poor communication between Dr G. and Dr R. with inconsistent accounts of conversations
• Lack of contemporaneous documentation of clinical advice given
• Delayed antibiotic administration (6:02pm vs required by noon)
• Initial P3 (6-hour) retrieval priority rather than P1 (1-hour) priority
• Failure to use available access line to speak directly with consultant
• Inadequate transmission of clinical information (observations data, full pathology results not provided to consultant)
• No maternal sepsis guidelines available at the hospital
• High CRP result (361.8 mg/L) not immediately communicated to treating doctor

Coroner's recommendations

1. Lower respiratory rate threshold in Gove sepsis protocol to ≥20 breaths per minute to align with Mayo Clinic standards and enable earlier recognition of sepsis
2. Lower heart rate threshold in RDH sepsis protocol from ≥120 to ≥110 bpm to match Gove protocol and Mayo Clinic standards
3. Medical doctors making statements for inquest must make statement as soon as possible, refer to clinical notes, date the statement, and not refer to statements of others
4. Establish and monitor Emergency Department access line for direct consultant contact as essential infrastructure for all rural medical outposts in Northern Territory
5. Implement mandatory use of Telehealth camera service as diagnostic tool for rural area medical staff seeking consultant advice, with education for all NT Health doctors
6. Implement requirement for contemporaneous written notes of all clinical advice sought from consultants, with immediate placement on patient clinical records
7. Ensure pathology results provided in full and not partially; notify requesting doctor immediately if test results are to be re-run
8. Implement training and ongoing professional development for all medical staff regarding sepsis recognition, necrotising fasciitis diagnosis, and related conditions
9. Endorse and monitor implementation of revised Careflight retrieval priority procedures
10. Implement improvements to MEWS (Modified Early Warning Score) system including mandatory urine output monitoring
11. Implement early recognition of sepsis protocol with specific callout for Careflight early retrieval when severe sepsis suspected
12. Implement protocol to specify early transfer for patients with suspected surgical source of infection including necrotising fasciitis
13. Extend sepsis recognition protocols and maternal sepsis guidelines to all rural hospitals in Northern Territory and Australia-wide