Jacobs, Roy Rodney

Contributing factors

• Failure to perform ECG despite markedly elevated heart rate (152 bpm)
• Failure to recognise alternative diagnoses (cardiac disease) in patient presenting with tachycardia
• Clinical focus on intoxication and alcohol withdrawal rather than other serious causes
• High Q-ADDS scores (6-7) not triggering appropriate escalation or medical review
• Inadequate frequency of observations overnight despite high Q-ADDS scores
• Failure to seek consultation with tertiary facility or Retrieval Services Queensland despite markedly abnormal vital signs
• Nursing staff lack of understanding of Q-ADDS escalation triggers despite training
• Absence of formal medical handover between day and night medical officers
• Inadequate medical review overnight despite high-acuity patient
• Locum medical officer reliance on nursing report rather than reviewing high Q-ADDS scores
• Patient misattribution: vital sign abnormalities attributed to pain and alcohol withdrawal rather than cardiac causes
• Underlying severe triple-vessel coronary artery disease with critical LAD stenosis not identified

Coroner's recommendations

1. Clarify application of Q-ADDS action plans to medical staff - specifically whether actions required by Q-ADDS scores are mandatory or advisory, and ensure this is clarified on the tool itself and in supporting procedures and training
2. Strengthen training and evaluation for medical officers on Q-ADDS/CEWT/Q-MEWT tools, with particular attention to locum medical workforce access to regular training
3. Review effectiveness of online Q-ADDS training module - address the ability of users to skip the video component and incorporate testing of user understanding
4. Implement formal medical handover process between day and on-call medical officers (which has since been done)
5. Ensure all clinical staff understand that Q-ADDS scores mandate corresponding actions unless parameters have been formally modified and documented by senior medical officer
6. Embed early deterioration detection and clinical escalation in daily clinical practice and culture through effective training, compliance monitoring and proactive feedback
7. Implement local compliance auditing of Q-ADDS charts to identify underlying reasons for non-compliance
8. Improve recruitment and retention of permanent medical staff at rural facilities to reduce reliance on locum medical officers
9. Provide enhanced orientation for locum medical officers including specific training on hospital policies, procedures and early warning systems
10. Establish clear escalation protocols for rural hospitals when patients present with markedly abnormal vital signs and unclear diagnoses
11. Department of Health to fund research to identify and address sociocultural factors influencing compliance with hospital care escalation systems