Scholz, Karl David

Contributing factors

• Premature extubation only 15 hours after surgery without adequate consultation between intensive care and surgical teams
• Failure to communicate documented clinical signs (difficulty swallowing, elevated temperature) from morning shift to consulting intensivist prior to ward transfer
• First episode of respiratory distress on 20 May morning treated with reassurance and paper bag rather than proper medical evaluation and documentation
• Misdiagnosis by intensive care fellow Dr K. of upper airway obstruction as lower respiratory tract mucous plug problem
• Failure to escalate second episode of respiratory distress (at 15:30) to senior intensivist; patient left on ward rather than admitted to intensive care
• Inadequate physical examination (no laryngoscope used) by Dr K. despite known history of airway compromise from dental infection
• Lack of communication between Dr K. and patient/family regarding severity of condition
• Small bore endotracheal tube (6.5 RAE) used may have contributed to difficulties and was typically designed for short-term use

Coroner's recommendations

1. Development of a new nursing discharge form when transferring from intensive care to ward, including a bold red box headed 'special risk/issues about this patient'
2. Implementation of audit process to review compliance with the discharge form procedure
3. Insertion of similar risk highlighting sections into surgical operation notes
4. Development of staff orientation program to inform all staff that visiting medical officers must provide sufficient clinical information to be 'handed over' on admission to ward
5. Implementation of weekly rolling audit of emergency buzzers by security staff and monthly audit by contractor, with results recorded and audited
6. Emphasis on standards for documentation, communication and clinical handover for all staff
7. Importance of communication between anaesthetist, surgeon and intensive care specialist
8. Recognition of potential for life-threatening developments of dental infections
9. Review and improvement of medical record documentation practices in intensive care