Anderson, John Clive

Contributing factors

• delayed specialist referral for suspected endocarditis
• failure to expedite referral despite clinical suspicion
• non-urgent triage (category B) by hospital specialist unit
• uncontrollable sepsis post-operatively
• newly identified ventricular septal defect complicating recovery
• development of complete heart block
• multiple organ failure
• intravenous drug use history
• poor dentition
• hepatitis C positive status

Coroner's recommendations

1. Treating general practitioners of prisoners should be mindful of elevated risk of infective endocarditis in the prisoner population and seek prompt specialist review based on clinical judgment upon identifying significant symptoms
2. Specialists receiving referrals from general practitioners should consider contacting the referring practitioner to discuss referrals where the risk to the patient is serious and the patient is a prisoner with elevated risks, particularly when specialist triage conclusions differ from the GP's clinical suspicion
3. Specialists performing triage should document the basis of their triage decision in similar fashion to how referring doctors are asked to provide information on which referrals are based
4. Referring doctors in correctional services should actively proactively monitor referral processes to ensure patients are under consideration of appropriate specialists, particularly when security delays prevent earlier notification of specialist appointments
5. Referring doctors should persist in establishing communication with specialists by contacting different hierarchical levels when first met with impediment, especially in the context of serious suspected diagnoses
6. General practitioners should include all pertinent clinical information in referral letters for suspected infective endocarditis, including recent dental treatment, characteristic lesions (erythematous macules/Janeway lesions), and systemic symptoms, as this information is critical for specialist assessment