Platt, Christopher Robert Edmund - Non-inquest findings

Contributing factors

• Failure to recognise early signs of serious intra-abdominal pathology on first presentation (elevated WCC, x-ray findings, low albumin, tachypnoea, low oxygen saturations)
• Misdiagnosis of constipation with overflow incontinence when presentation was consistent with diverticulitis/ischaemic bowel
• Administration of enemas which may have been harmful in context of possible ischaemic bowel or diverticulitis
• Delayed x-ray reporting (not reported until next day)
• Inadequate assessment of cause of immobility and clinical deterioration
• Poor clinical handover between multiple staff members
• Inadequate documentation of clinical assessments and discussions
• Failure of senior clinician (Dr B.) to recognise red flags and high-risk patient
• Failure to act on elevated white cell count in context of other findings
• Insufficient investigation prior to discharge despite signs of serious illness
• Family concerns about discharge not adequately addressed or documented
• Lack of formal consultation requirement with ED consultant prior to discharge at that time

Coroner's recommendations

1. Completion of work around Clinical Handover for West Moreton Hospital and Health Service with implementation of formal procedure and auditing program based on National Standards incorporating both verbal and written handover
2. Review and update the Clinical Documentation procedure (DWMProc201000580) with all staff made aware upon publication
3. Conduct random chart audit to identify documentation deficiencies with audit report to identify remedial actions and be tabled at Hospital and Health Service Executive Safety and Quality Meeting
4. Implementation of Adult Deterioration Detection System (ADDS) throughout the Health Service for early identification and response to patient deterioration