Coronial
QLDhospital

Mulhall, Terrance - Non-inquest findings

Deceased

Terrance Mulhall

Demographics

48y, male

Coroner

McDougall

Date of death

2011-12-14

Finding date

2015-03-30

Cause of death

myocardial infarction due to ischaemic heart disease due to hypertension

AI-generated summary

A 48-year-old man died from myocardial infarction due to ischaemic heart disease and hypertension shortly after undergoing urology surgery. Critical failures in clinical communication prevented recognition of undiagnosed angina before surgery. The patient presented to ED with chest tightness, nausea and left arm tingling, suggesting angina, but this diagnosis was not communicated to his GP, urologist or anaesthetist. The anaesthetist was unaware of documented hypertension, current antihypertensive medication, or recent cardiac symptoms when assessing the patient preoperatively. The patient was a poor historian who didn't understand his own medical conditions. Multiple system failures included: non-receipt of ED referral letter by GP; inaccessible medical records due to EMR transition; and lack of ED-to-anaesthetist communication. The hospital subsequently implemented significant improvements to EMR systems, device access, and inter-departmental communication protocols.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

anaesthesiaurologycardiologyemergency medicine

Error types

communicationdiagnosticsystem

Drugs involved

telmisartanpantoprazole

Clinical conditions

ischaemic heart diseasehypertensionangina pectorismyocardial infarctionrenal calculigastro-oesophageal reflux disease

Procedures

ureteric stent insertionrepeat urology surgery

Contributing factors

  • failure to diagnose and communicate angina from ED to primary care and surgical team
  • anaesthetist unaware of patient's hypertension and antihypertensive medication
  • anaesthetist unaware of recent cardiac symptoms (chest tightness, nausea, tingling in arm)
  • inaccessible medical records due to EMR system in early implementation
  • non-receipt of ED referral letter by GP recommending stress testing
  • poor communication between ED, GP, urology and anaesthesia
  • patient was a poor historian with limited understanding of his medical conditions
  • lack of EMR access and computers in operating theatre area
  • no temporary file system to accompany patient with essential records
  • lack of cardiology review despite symptoms suggestive of angina

Coroner's recommendations

  1. Executive Director of Emergency and Critical Care and Support Services should review the system for disseminating information to primary care providers when patients are discharged from ED, including audit of communication frequency, analysis of methods, risk analysis of information acuity, and development of work instruction with clear responsibility lines
  2. Executive Director of Surgery should review barriers to anaesthetists conducting thorough pre-anaesthetic assessments, including pressure on teams during long operating lists and accessibility of hard copy and EMR records before surgery
  3. Improve accessibility of EMR records in every area where anaesthesia is undertaken
  4. Enhance EMR user interface and reliability of summaries
  5. Establish designated duty anaesthetist availability
  6. Create means of identifying patients with uninvestigated angina using EMR Alerts section
  7. Implement temporary file system with scan-on-discharge model for patient records
  8. Increase availability of computers and laptops for EMR access in operating theatres
  9. Review order of filing notes in EMR to simplify chart review
  10. Develop process to pre-order old medical charts for patients preoperatively
  11. Establish electronic transmission of ED discharge summaries to GPs
Full text
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