Biffin, Albert Eric

Contributing factors

• Incarcerated umbilical hernia containing ischaemic small bowel
• Hernia recurrence or incomplete initial reduction approximately 30 hours after manual reduction and strapping
• Inadequate GP history-taking and examination before hernia reduction
• GP assessment limited without reviewing nursing notes or prior facsimile communication
• Inadequate documentation of GP's verbal instructions to nursing staff
• Ineffective nursing handover between shifts
• Staff unfamiliar with Mr Biffin caring for him in final days
• Clinical nurse's vague verbal instruction to enrolled nurse without documented assessment
• Failure to escalate despite documented deterioration signs (falling BP, confusion, lethargy, reduced oral intake, changed behaviour)
• Nursing staff focus narrowly on constipation rather than overall condition assessment
• Concurrent bronchopneumonia
• Coronary artery disease with pacemaker
• Advanced age with multiple comorbidities

Coroner's recommendations

1. Blue Care should introduce a requirement for personal carers and assistants in nursing to document any variation in a resident's condition in the progress notes, including to whom it was escalated, with enrolled nurses or registered nurses recording their assessment and response
2. Blue Care should encourage visiting medical officers to document the diagnosis and management plan, including any planned review and indications for earlier escalation, with training for nursing staff to request such documentation from doctors, ensuring written records of instructions sufficient to guide nursing staff across shift changes and clarify when doctor or emergency services should be contacted
3. Blue Care should consider further training of personal carers and assistants in nursing to authorise them to make entries in medical records where appropriate, recognising these staff often have greatest continuity with residents and appreciation of changes in wellbeing