Crane, Sylvia - Non-inquest findings

Contributing factors

• five month delay in scheduling Category 1 surgery for nephrectomy
• systemic waitlist management failures at RBWH Department of Urology
• communication failure between Hervey Bay Hospital and RBWH urology team regarding patient presentation and symptoms in September 2012
• absence of documentation in RBWH records of contact from Hervey Bay Hospital about patient's admission
• treating surgeon at RBWH unaware of patient's hospital admission and changing symptoms
• rapid and rare progression of renal tumour with invasion into inferior vena cava
• no established referral pathways for regional patients to appropriate local hospitals
• theatre lists fully booked with competing waitlist management pressures for multiple patient categories

Coroner's recommendations

1. RBWH Surgical & Perioperative Services should consider reviewing the access criteria for the Department of Urology in relation to less acute referrals to enable more timely management of urgent and complex cases
2. Continue implementation of improved waitlist management processes including daily case discussions, prioritisation according to clinical need, and use of waitlist streaming strategies
3. Maintain current processes ensuring Category 1 patients are booked for surgery on the day they are considered ready for care
4. Review pathways for referrals from regional hospitals to ensure patients are referred to appropriate local services where capabilities exist
5. Ensure adequate communication and documentation of inter-hospital contacts regarding patient clinical changes and admissions