Hornby, Geoffrey John
Deceased
Geoffrey John Hornby
Demographics
58y, male
Date of death
2010-03-21
Finding date
2013-04-16
Cause of death
Respiratory failure due to or as a consequence of Chronic Obstructive Pulmonary Disease
AI-generated summary
Geoffrey Hornby, a 58-year-old prisoner with significant COPD, ischemic heart disease, and multiple comorbidities, died from respiratory failure secondary to COPD. He was admitted to hospital with COPD exacerbation and deteriorated rapidly while in the Secure Unit at Princess Alexandra Hospital, developing cardiac arrest on 17 March 2010. Critical delays occurred in recognising cardiac arrest and commencing CPR, with chest compressions not begun until approximately 1 minute 37-55 seconds after pulse loss. The coroner found the delay was small and reasonable given the challenging environment, PAH policies, and lack of clear clinical leadership among nursing staff. However, the coroner identified that better communication, a nominated team leader, and improved environmental controls (lighting) could have facilitated faster recognition and response. Expert opinion concluded the delay was unlikely to have changed the outcome given his severe comorbidities.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Rapid deterioration in Secure Unit environment
- Delay in recognising cardiac arrest
- Delay in commencing CPR (approximately 1 minute 37-55 seconds from pulse loss)
- Lack of designated Team Leader among nursing staff
- Poor communication between Secure Unit nurses and rapid response team nurses
- Dim lighting in patient room
- Cardiac arrest in setting of severe COPD exacerbation
- Coronary atherosclerosis and ischemic heart disease as contributing medical conditions
Coroner's recommendations
- PAH review relevant procedure manuals to ensure current training on leadership and followership in emergency response scenarios is reflected in written policies
- PAH provide guidance on how a Team Leader should be chosen in emergency situations when a doctor is not immediately present
- PAH emphasise importance of controlling environmental factors such as lighting when responding to emergencies
- PAH provide guidance to staff involved in incidents about discussion with other witnesses after the event, balancing debriefing, counselling, and administration of justice
- PAH introduce training scenarios emphasising control of environmental factors such as lighting during emergency response
- PAH ensure both nurses and doctors in rapid response teams receive familiarisation training in all hospital areas to quickly locate and operate equipment
- PAH consider practical measures to ensure Team Leader is easily identifiable during Code Blue, such as stickers or badges, particularly where teams comprise staff from multiple areas
Full text
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