Talbot, James Patrick

Contributing factors

• failure to communicate findings of abdominal distension to treating physician
• Team Leader absence without replacement during critical ward round
• no nurse accompanying physician on ward round
• physician did not read nursing progress notes documenting distended abdomen
• physician did not perform abdominal examination on 30 December
• physician did not perform abdominal imaging despite vomiting and abdominal distension
• inadequate response to family concerns raised by daughter in afternoon
• failure to obtain ordered urine sample, delaying alternative diagnosis consideration
• absence of formal escalation process for patient and family concerns
• lack of documentation of clinical decisions on handover sheets
• atypical presentation without significant pain, complicating diagnosis

Coroner's recommendations

1. Wesley Hospital should review current practices to ensure matters raised during flagging handover are documented on handover sheets
2. Senior Registered Nurse should review the process for updating information on handover sheets to ensure distension and other critical findings are recorded
3. Wesley Hospital should clarify handover process when patients are transferred between rooms to ensure allocated nurse formally hands over care
4. Hospital has implemented Q-ADDS (Queensland Adult Deterioration Detection System) as escalation mapping tool
5. Hospital has introduced Team Leader Resource Guide with minimum rostering requirements and sick leave replacement protocols
6. Hospital has adopted 'Let us Know' tool (similar to 'Ryan's Rule') for patients and families to escalate concerns directly
7. Hospital has developed protocol ensuring MSU samples are collected and tested promptly
8. Hospital has provided education on SHARED (Situation, History, Assessment, Risk, Expectation, Documentation) handover framework
9. Hospital has implemented graded assertiveness and communication training for nursing staff
10. Hospital has introduced Medical Care Coordinator role to assist complex and cognitively impaired patients
11. Hospital has engaged specialist education teams to promote higher standards of individualised elderly care
12. Hospital is developing process for proactive discussion and documentation of clinical treatment goals and limits to treatment escalation