Paton, Daniel William

Contributing factors

• Undisclosed obstructive sleep apnoea not revealed at pre-operative assessment
• Morbid obesity (BMI 40)
• Probable respiratory infection or pneumonia (brown secretions in endotracheal tube)
• Morphine via patient-controlled analgesia device
• Temazepam and Phenergan co-prescribed without Acute Pain Management Service consultation
• Inadequate pre-anaesthetic risk assessment on day of surgery
• Incomplete and unreliable nursing observations and documentation
• Non-contact with Acute Pain Management Service when clinical deterioration occurred
• Transfer to another ward disrupting continuity of care
• Insufficient intervals between observations in ward 8AN
• Opioid tolerance not reliably documented
• Failure to escalate to senior medical staff

Coroner's recommendations

1. Review and strengthen the integrated pre-operative assessment process to ensure patients with significant risk factors (morbid obesity, sleep apnoea risk factors, uncontrolled pain requiring narcotics) are referred for formal anaesthetic risk assessment by an anaesthetist prior to the day of surgery
2. Ensure anaesthetists do not conduct first patient assessment on the day of elective surgery; postpone procedures if pre-operative assessment reveals uncontrolled or poorly understood medication regimes or undisclosed risk factors
3. Implement systems to ensure completion of integrated assessment forms with explicit identification of anaesthetic risk factors including sleep apnoea screening
4. Establish and enforce mandatory protocols requiring consultation with the Acute Pain Management Service before co-prescribing sedatives (such as Temazepam) with patient-controlled analgesia morphine
5. Provide mandatory education to all medical and nursing staff involved in post-operative care regarding PCA safety protocols and the prohibition on sedative co-prescription without pain management service consultation
6. Implement sedation scoring systems and comprehensive observation protocols for patients on PCA, including assessment of level of consciousness, respiratory rate, oxygen saturation, temperature, and carbon dioxide levels (not relying on oxygen saturation alone)
7. Establish clear guidelines that observations for PCA patients must continue at specified intervals (hourly for first 4-6 hours, then two-hourly) and be reliably recorded on the appropriate acute observation form
8. Ensure accurate, contemporaneous documentation of all observations on the correct charts; implement systems to prevent alteration or overwriting of clinical records
9. Establish protocols requiring direct contact between ward staff and the Acute Pain Management Service when a patient on PCA develops clinical concerns (drowsiness, low oxygen saturation, behavioural changes), rather than delaying or transferring to another ward
10. Ensure continuity of care by conducting thorough clinical handovers when patients on PCA are transferred between wards, including review of recent observations and clinical trajectory
11. Train ward supervisors and nursing staff to escalate clinical concerns to senior medical staff and specialist services rather than managing behavioural incidents in isolation; ensure clear pathways to on-call anaesthetists and pain management services are understood
12. Review policies regarding patient transfer decisions to ensure such decisions are made on clinical grounds and documented as such, rather than for social or staff convenience reasons
13. Establish clear escalation protocols for junior doctors (ward call doctors) to contact senior registrars or consultants when facing complex post-operative pain management situations, and to formally request senior attendance rather than offering passive consultation
14. Implement training for junior medical staff regarding specialist services available 24/7, particularly the Acute Pain Management Service, and the indications for their involvement
15. Review anaesthetic and pain management guidelines within the hospital regarding background infusion rates for PCA morphine, sedating medication interactions, and monitoring requirements, particularly in high-risk patients (obese, suspected sleep apnoea, opioid tolerant)
16. Facilitate ongoing liaison between the hospital and the Australian Society of Anaesthetists regarding debate over safe levels of anaesthetic and sedating medications, background infusion protocols, and monitoring practices
17. Consider policy review regarding intensive care admission thresholds for post-operative patients with risk factors for respiratory depression (obesity, sleep apnoea, respiratory infection) to ensure close monitoring