Inquest into the death of Judith Smart

Contributing factors

• Inadequate post-operative nursing observation in PACU
• Inappropriate modification of oxygen saturation discharge criteria without thorough clinical review
• Discharge from PACU to general ward despite dropping oxygen saturations and need for frequent rousing
• Morphine PCA prescribed without adequate risk stratification for OSA and COPD
• Absence of CPAP machine at bedside despite OSA diagnosis
• Lack of continuous pulse oximetry monitoring on general ward
• Reduced nursing ratios (1:6) on general ward inadequate for high-risk post-operative patient
• Absence of Close Observation Unit for intermediate-risk patients
• Inadequate end-of-life care and palliative team communication
• Lack of protocols for management of personal belongings including CPAP machines
• Staffing pressures on Floor Anaesthetist
• Missing evening Anaesthetic Registrar (staff shortage)

Coroner's recommendations

1. NT Health has implemented a new Post-Anaesthesia Care Unit Guideline mandating screening for OSA in pre-admission clinic and requiring CPAP machines to be physically present before PACU discharge
2. NT Health should develop and promulgate a policy/guideline for how patients are reunited with personal belongings following surgery
3. Additional Anaesthetic Registrar now rostered to support busy afternoon period and second on-call consultant on weekday evenings to reduce staffing pressures
4. Additional PACU nurse rostered overnight to relieve pressure on PACU nurses to discharge patients prematurely
5. Close Observation Unit (COU) being established in Ward 3A with capacity for four patients, one dedicated nurse, and continuous pulse oximetry monitoring for high-risk patients not suitable for general ward
6. Further consideration and guidance should be given concerning circumstances where continuous CPAP use may be indicated post-operatively
7. Comfort Care Pathway being developed for patients requiring end-of-life care when transfer to Hospice not possible; trial commenced 1 July 2024
8. ICU End-of-Life Care Guideline now provides guidance on palliative care management, prioritising single room transfer and ensuring medication availability on eMMa system prior to transfer
9. Improved communication procedures with families regarding reportable deaths required moving forward