Burgen, Deborah Denise

Contributing factors

• Delayed diagnosis of mechanical bowel obstruction across six emergency department presentations
• Failure of senior doctors to adequately support junior medical officers
• Delay in operative intervention until bowel perforation occurred
• Inadequate post-operative monitoring for internal bleeding
• Failure to insert central venous line on admission to ICU
• Delayed intubation of critically ill patient
• Inadequate medical leadership in ICU with conflicting instructions from anaesthetists
• Sub-therapeutic antibiotic dosing
• Lack of proper orientation and credentialing of overseas-trained doctors in senior positions
• System failures in triaging and investigation of emergency department patients
• Failure to escalate concerns raised by experienced nursing staff

Coroner's recommendations

1. Mt Isa Hospital managers develop a system to ensure policies are periodically audited for compliance and those who do not discharge their responsibilities are held accountable
2. Clinical managers of MIBH review the manner in which patients presenting to the emergency department are triaged to eliminate failures in pre-admission care, including: ensuring all emergency blood tests and scans are done immediately with results provided same day; requiring senior doctor review of any patient attending twice with same condition; considering immediate admission for any patient attending twice with same symptoms and unclear diagnosis
3. Queensland Health pursue telemedicine video links as an urgent priority to enable access to specialist consultation in remote locations