Talbot, James Patrick
Deceased
James Patrick Talbot
Demographics
87y, male
Date of death
2013-12-31
Finding date
2016-07-08
Cause of death
Strangulated small bowel due to adhesions from previous abdominal surgery
AI-generated summary
An 87-year-old man with diabetes, hypertension and dementia was admitted with presumed UTI and dehydration. Within 24 hours, nursing staff observed a distended abdomen and bile-stained vomiting—clinical signs of bowel obstruction. Despite these findings being documented and communicated verbally at handover, the information failed to reach the treating physician at ward round due to system failures: the Team Leader became unwell and was not replaced, no nurse accompanied the physician, and he did not read nursing notes. The physician did not perform abdominal examination and ordered a CT head instead of abdominal imaging. The patient subsequently aspirated and died from strangulated small bowel due to adhesions. Even if diagnosed, surgery was likely non-viable; the critical failure was that the patient and family were denied opportunity to discuss palliative care options.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
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
- Wesley Hospital should review current practices to ensure matters raised during flagging handover are documented on handover sheets
- Senior Registered Nurse should review the process for updating information on handover sheets to ensure distension and other critical findings are recorded
- Wesley Hospital should clarify handover process when patients are transferred between rooms to ensure allocated nurse formally hands over care
- Hospital has implemented Q-ADDS (Queensland Adult Deterioration Detection System) as escalation mapping tool
- Hospital has introduced Team Leader Resource Guide with minimum rostering requirements and sick leave replacement protocols
- Hospital has adopted 'Let us Know' tool (similar to 'Ryan's Rule') for patients and families to escalate concerns directly
- Hospital has developed protocol ensuring MSU samples are collected and tested promptly
- Hospital has provided education on SHARED (Situation, History, Assessment, Risk, Expectation, Documentation) handover framework
- Hospital has implemented graded assertiveness and communication training for nursing staff
- Hospital has introduced Medical Care Coordinator role to assist complex and cognitively impaired patients
- Hospital has engaged specialist education teams to promote higher standards of individualised elderly care
- Hospital is developing process for proactive discussion and documentation of clinical treatment goals and limits to treatment escalation
Full text
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