Mead, Gwendoline

Contributing factors

• Persistent unexplained low post-operative urine output not responsive to repeated fluid challenges
• Evolving acute kidney injury not recognised in timely manner despite meeting KDIGO criteria by urine output
• Significant hypoalbuminaemia from malignancy and malnutrition increasing third-space fluid losses
• Lack of formal medical team involvement despite eight Ward Call reviews and one MET call for recurring hypotension and oliguria
• Failure to recognise clinical pattern of repeated interventions with transient response indicating need for second opinion
• Removal of indwelling catheter on day 6 post-op preventing accurate monitoring of urine output despite medical team recommendation for strict fluid balance monitoring
• Development of urosepsis (Pseudomonas aeruginosa) on day 6 post-operatively
• Acute decompensation requiring ICU readmission on day 9
• Femoral artery injury during attempted arterial line insertion
• Uncontrolled bleeding and coagulopathy refractory to intervention
• Pre-existing reduced renal reserves from previous acute kidney injury in November 2014

Coroner's recommendations

1. DDHHS should examine and formally report on review of the SOMDT model to ensure the correct treating surgical team is allocated to and notified when their patient requires investigation and treatment of complications emerging during neoadjuvant therapy phase prior to surgery
2. Consider whether patients unable to complete planned neoadjuvant therapy should be represented to SOMDT for reconsideration of surgical approach prior to planned surgery
3. Implement system to identify patients with multiple MET calls or escalations for recurring problems for timely senior clinician review and comprehensive investigation
4. Establish structured communication protocol between senior members of treating teams when multiple MET calls occur for same patient to facilitate earlier escalation to more intensive treatment if appropriate
5. Develop and implement capability in electronic patient flow management system to record and action formal requests for inter-team patient review with automatic alerts to clinicians and tracking until review completed
6. Monitor implementation of electronic vital signs recording (planned for 2018) to enable automatic triggers for persistent low urine output
7. Establish awareness and education about perioperative medicine approach for management of elderly complex surgical patients as resources allow
8. Strengthen clinical documentation standards across all staff with emphasis on timing and completeness of all clinical entries including Ward Call reviews
9. Copies of findings to be forwarded to Colorectal Surgical Society of Australia and New Zealand and Royal Australasian College of Surgeons regarding importance of surgical teams actively considering differentials for persistent low urine output and seeking second opinion as part of routine post-operative management