Plumb, Joshua Jai

Contributing factors

• Delayed formal observations - 10:00pm observations not performed until 11:10-11:15pm (over one hour late)
• Lack of documented nursing care plan
• Team nursing model without explicit task assignment creating ambiguity about responsibility
• Insufficient frequency of visual checks after 9:30pm
• Bed bumpers not firmly secured, allowing entrapment risk
• No continuous supervision despite patient's inability to communicate distress or move independently
• Bed rails with vertical bars designed to standard no longer compliant with Australian standards
• Inadequate staffing levels not escalated to management
• Failure to recognize high-acuity needs requiring specialling despite previous incident of entrapment on 3 September 2010

Coroner's recommendations

1. Nurse training should be reviewed to highlight: (a) the responsibility of the team leader nurse to continually consider the need for additional staffing and communicate such needs assertively; (b) the responsibility of appropriate nurse roles to actively enquire, assess and respond to unit capacity for adequate nursing services; (c) emphasis on training staff to assess risk and prioritise competing demands to maximise patient safety; (d) review of the Team nursing model to ensure a documented plan assists in identifying necessary tasks and aids communication between team members
2. Patient Safety Queensland should continue to be sufficiently funded and resourced to continue and complete reviews and vital work to improve patient safety state-wide, particularly given the advent of independent hospital districts
3. Educational follow-up should be arranged between the Office of the State Coroner and investigating police to ensure greater knowledge and cooperation in investigating matters for the coroner
4. Queensland Health should complete the Root Cause Analysis process or otherwise complete the review of bed and bed bumper related safety issues, particularly in the context of children and children with disabilities
5. Standards for care of children with special needs should apply across the state
6. Completion of root cause analysis should disseminate results across Queensland Health to ensure state-wide improvement of patient safety
7. If bed bumpers are used, they must be firmly secured not just to the top bed rail, but also to the base of the bed/mattress and to each end of the bed to eliminate risk of the mat being forced between the rails. Consideration of the 'breathability' of bumper material could be undertaken. The better course appears to be removal state-wide of their use, with increased nursing resources to 'special' patients where necessary
8. Children with special needs and high acuity should be admitted to beds with direct visualisation from the nurses' station where possible, and if a patient or carer cannot stay with the child, a nursing special should be allocated to stay with the patient at all times with hourly documented visual checks
9. A working party reviewing available bed types and matching appropriate beds to the child's age and size should continue
10. The Children's Early Warning Tool (CEWT) may require adjustment and fine-tuning when applied to children with special needs, potentially to be manipulated to reflect the needs of particular children whose readings might fall outside usual parameters