Mathers, John William

Contributing factors

• Transport to nearest hospital rather than equipped trauma centre
• Staff used infusion pump without adequate training
• Safety warnings about infuser not read by staff
• Air detection clamp not attached to infuser despite safety alert
• Instructions from senior anaesthetist not communicated to all theatre staff
• Delay in consulting senior surgeon—he was at lunch during patient deterioration
• Equipment safety alert issued but clamp not acquired by hospital
• Chaotic, stressful operating theatre environment during critical case

Coroner's recommendations

1. Queensland Ambulance Service to develop protocol for transporting severe trauma patients to nearest hospital with appropriate emergency trauma services, rather than simply the nearest hospital
2. Better policies and procedures for training and supervision on use of medical equipment such as Level 1 infuser, including requirement to read manuals and understand safety warnings
3. Ensure laminated safety warnings are attached to infusion pumps as recommended by distributors
4. Better policies and procedures to ensure instructions from senior anaesthetist are communicated to all operating theatre staff
5. Hospitals not adequately equipped for severe trauma cases should have protocols ensuring most senior surgeon available is immediately consulted on admission of critical cases
6. Audit of all equipment in Queensland public hospitals subject to safety alerts to ensure warnings are attached or equipment removed from use
7. Conduct audit of all Level 1 infusers in Queensland public hospitals to ensure required air detection clamps are acquired and available
8. Establish formal process ensuring autopsy reports are sent to hospitals in cases of death during surgical procedures for morbidity review
9. Improve processes for timely provision of medical staff statements to police investigators
10. Investigate use of tests other than visual inspection to determine presence of patent inter-ventricular septum in patients who die from air embolism
11. Review processes for obtaining antemortem blood samples from hospitals as part of autopsy investigations