Wright, Verris Dawn; Carter, Jasmyn Louise

Contributing factors

• failure to recognise signs of sepsis
• failure to escalate clinical concerns to senior staff
• communication failures between nursing and medical staff
• doctor's mobile phone was uncharged and alternative number not available
• inadequate implementation and understanding of Q-ADDS observation tool
• failure to establish documented management plans
• inappropriate triage category and failure to activate emergency response
• absence of frequent observations and vital sign monitoring
• complacency and indifference toward escalation tools and procedures
• inadequate out-of-hours clinical supervision
• distraction of staff completing administrative tasks rather than patient-centred care
• confirmation bias: clinicians formed subjective opinions justifying symptoms without considering sepsis
• incomplete handover of clinical information
• no documented orders for continued fluid administration or monitoring

Coroner's recommendations

1. Queensland Health to conduct research into the validation of the Q-ADDS tool
2. Queensland Health to conduct research to identify and address the sociocultural factors that influence compliance with existing hospital care escalation systems
3. DDHHS to consider a protocol for advising family of patient deterioration immediately upon staff becoming aware of such deterioration, so family can attend or be aware of their loved one's condition in a timely way
4. Continue monitoring compliance with use of Q-ADDS observation tool and ED Q-ADDS observation tool through S.A.F.E audit program
5. Implement sepsis awareness program and develop competency-based deterioration patient education module
6. All admitted patients must have documented Admission Management Plan with clearly specified treatment and observation requirements
7. Create patient-focused culture with clinician accountability for safe practice standards
8. Review and improve out-of-hours hospital supervision and clinical support arrangements with dedicated Clinical Nurse on roster
9. Review and restructure emergency department model of care including: management of high volume category 4 and 5 presentations, additional medical officer resources for out-of-hours work, ensure competent experienced emergency nurse rostered all shifts, upgrade Clinical Nurse position to permanent Associate Nurse Unit Manager, roster nurse practitioner to peak activity times, extend administration officer hours for out-of-hours coverage