Hammett, Christopher

Contributing factors

• Failure to identify aspiration as cause of initial oxygen desaturation in PACU
• Inadequate investigation of critical desaturation event (64% SpO2)
• Assumption of airway obstruction without clinical examination for aspiration
• Poor communication during handover from PACU to ward regarding desaturation event
• Failure to escalate to medical staff despite escalating oxygen requirements
• Inadequate nursing monitoring and observations in post-operative period
• Unexamined increase in oxygen supplementation without physician notification
• Nursing staff disengagement and failure to provide appropriate supervision
• Falsification and overwriting of patient observations in medical records
• Delayed recognition of severe deterioration (oxygen saturation 60%)
• Morphine-induced respiratory depression compounding aspiration pneumonia
• Underlying coronary atherosclerosis compromising ability to tolerate hypoxaemia

Coroner's recommendations

1. Implement multimodal analgesia as standard in operating theatre
2. Establish policy requiring arterial blood gas analysis and consideration of chest X-ray after prolonged post-operative desaturation
3. Consider admission to high dependency unit after prolonged desaturation or significant oxygenation compromise
4. Review policy to record all narcotic boluses given to patient in medical notes
5. Establish minimum length of stay in PACU after narcotic administration
6. Establish minimum length of stay in PACU after prolonged desaturation episodes
7. Implement policy requiring medical staff notification if oxygen saturations fall below critical levels
8. Review PCA order forms to include specific notification criteria for clinical deterioration
9. Review appropriateness of nursing-to-patient ratios on post-operative wards
10. Review appropriateness of shift coordinator being located in separate hospital and geographically isolating Pacific Private Hospital during emergencies
11. Establish protocol for appropriate observations of patients with PCA pumps
12. Improve education and competency assessment of nursing staff regarding recognition of respiratory compromise
13. Establish liaison between Pacific Private Hospital and Royal Brisbane and Women's Hospital Acute Pain Management Team
14. Develop and implement Acute Pain Management Service Protocols including appropriate nursing observations and treatment
15. Provide ongoing education and consultations on acute pain management