Mr AC - Non-inquest findings

Contributing factors

• Severe untreated obstructive sleep apnoea not identified as perioperative risk
• Absent pre-operative physician assessment despite significant comorbidities
• Patient health history showing sleep apnoea not converted to anaesthetic alert
• Consultant anaesthetist failed to elicit sleep apnoea or prior anaesthetic complications
• No planned post-operative ICU admission despite high-risk profile
• Atrial fibrillation on ECG performed evening before death not reported to physician
• Chest x-ray findings not reviewed or reported
• Post-operative hypoxia with desaturation not escalated appropriately
• Lack of continuity of medical information between public and private sector
• Patient non-disclosure of recent surgical and anaesthetic complications

Coroner's recommendations

1. Ensuring Alert Sheet information is required for clinical handover and must be accurate
2. Reinforcing importance of complete pre-operative work-up of patients with obstructive sleep apnoea and other comorbidities
3. Routine consideration of ICU admission for post-operative monitoring of patients with obstructive sleep apnoea
4. Utilisation of risk screening tools and pre-operative communication with physicians to manage medically complex patients
5. Requesting complete patient file from referring Queensland Health hospitals for Surgery Connect patients undergoing elective surgery
6. Establishing clear responsibility for physician documentation of plan following investigation results
7. Ensuring physician follow-up of chest x-ray and ECG results
8. Standardising nursing practice to convey results of investigations ordered after hours to requesting medical officer
9. ICU willingness to accept elective patients with obstructive sleep apnoea for post-operative monitoring to be clearly communicated
10. Surgery Connect Agreement updated to require referring public hospital to provide all patient records when referring patients to private providers