Gulliver, Graeme Barry; Harrison, Joanne Lee; Morten, Aileen Margaret

Contributing factors

• Failure to order chest X-ray despite clinical signs and laboratory evidence of bacterial infection
• Failure to recognize significance of haemoptysis
• Failure to admit patient following appropriate investigations
• Inadequate staffing - no on-site doctor overnight at rural hospital
• Failure to calculate ADDS scores or act upon them
• Failure to comprehensively assess patient on admission
• Poor documentation and information transfer between nursing staff
• Reluctance of nursing staff to call on-call doctors out of hours
• Failure to action positive pathology results in timely manner
• Physician fatigue from unsustainable on-call scheduling
• Absence of on-site radiographer overnight
• Under-triage of acutely unwell patients
• Cultural failure to escalate concerns about deteriorating patients
• Lack of workplace embedding of recognition and management of deteriorating patients protocols

Coroner's recommendations

1. CHHHS implement the proposed workforce model at Mossman Hospital as soon as possible with at least one on-site senior medical officer overnight and report as to the implementation and its continuation to the Office of the State Coroner, annually for 5 years, with the first such report by 28 February 2015
2. CHHHS ensure that pathology testing laboratories and local General Practitioners and Medical Centres are provided with a direct telephone number for the Emergency Department for the Mossman and Atherton Hospitals which is answered at all times and through which the caller is able to be put through to the on duty medical officer
3. CHHHS and/or Queensland Health consider funding a full time radiographer at the Mossman Hospital
4. CHHHS and/or Queensland Health consider funding for a full-time nurse educator for the Hinterland Hub
5. Queensland Health appraise itself of the report and evidence of Professor Brown and educate its clinicians (doctors and nurses) as to the importance of acting upon haemoptysis, and the importance of not discounting haemoptysis as being likely due to a burst blood vessel from coughing
6. The Australian College of Rural and Remote Medicine, the Australian College of General Practitioners, the Australian College of Nursing, the Medical Board of Australia (Queensland Office) and the Nursing Board appraise themselves of the report and evidence of Professor Brown and consider disseminating information to their members as to the importance of acting upon haemoptysis and not discounting it as being due to a burst blood vessel from coughing