SM - Non-inquest findings

Contributing factors

• Failure to appropriately complete and interpret early warning observation tool (Q-ADDS) with incorrect scoring and failure to escalate
• Failure to investigate persistent low oxygen saturations from day 3 post-operatively
• Oxygen administered by nursing staff discretion without medical prescription or investigation of underlying cause
• Lack of oxygen prescribing and management procedures in the hospital
• Fractured clinical handover processes between surgical team and Hospital At Night team
• Inadequate identification and escalation of patient as outlier on wrong ward
• No documented VTE risk reassessment post-operatively despite reduced mobility
• Failure to obtain arterial blood gas analysis despite persistent hypoxia
• Atelectasis attributed to post-operative pain and poor mobilisation, shifting focus from other potential causes
• Ad hoc attendance at ward rounds and handovers preventing clear communication of clinical concerns

Coroner's recommendations

1. Undertake quality improvement project to improve compliance and completion of documented VTE risk assessment for VTE prophylaxis procedures
2. Implementation of oxygen prescribing procedures within the HHS and changes to national Inpatient Medication Chart to facilitate oxygen prescribing
3. Review and update HAN escalation triggers to include any patient with Q-ADDS score of 4 or more
4. Development and implementation of structured clinical handover process for all specialties encompassing all shifts
5. Establishment of linkage between ward and HAN team through Coordinated Care Stream Night Nurse Unit Manager attendance at evening HAN handover
6. System to flag serious events occurring in preceding 24 hours so clinical reviews must consider these events as part of assessment and management