Mrs H - Non-inquest findings

Contributing factors

• Delay in transporting admission blood samples to district hospital for testing
• Failure by senior medical officer (Dr D) to follow up outstanding blood results upon return to work on 5 April
• Lack of handover process between medical officers regarding outstanding pathology
• Delayed recognition of critical abnormalities in blood results (low sodium, impaired renal function)
• Faulty printer used for pathology result printing
• Limited clinical handover due to fatigue leave arrangements
• Inadequate monitoring of fluid balance and electrolytes despite reduced oral intake and immobility
• Communication and graded assertiveness issues between medical staff

Coroner's recommendations

1. All pathology results to be reviewed by the medical officer as soon as possible after pathology processing, either via hardcopy or electronically, and must be signed off and documented in patient records with treatment plan for any variances from normal
2. Orientation on how to access pathology results and use electronic systems must be provided to all medical staff (temporary and permanent) on commencement
3. Orientation including access to pathology results and electronic systems must be provided to all nursing staff
4. Develop HHS-wide procedure for pathology collection, review and action requiring every doctor to check and sign all laboratory results daily
5. Procedure for intravenous pantoprazole administration to be developed to ensure correct patient monitoring
6. All patients with low BMI on admission must be immediately referred to dietician; all patients with poor oral intake must have food and fluid balance charts
7. Intraosseous devices must always be available for emergency use; medical officers and registered nurses should have training in their use
8. All Q-ADDS charts must be correctly completed; all nursing staff must read and sign for escalation of clinical issues procedure
9. All clinical staff provided with training in assessing hydration/dehydration status; develop face-to-face scenario-based clinical deterioration training program
10. Family members should be involved in discussions about treatment plans where possible; all clinical staff to have refresher training in Ryan's Rule patient/family escalation
11. All nursing staff to receive graded assertiveness training and understand when to escalate clinical or workplace issues
12. ALL medical officers must be provided with orientation to HHS and local facility environment including escalation paths; orientation must include fatigue assessment and management
13. Revisit rostering for nursing staff to minimise cumulative fatigue
14. All patient transfers/retrievals for emergency management must have intravenous or intraosseous access and medical officer escort
15. Develop procedure for ward rounds including nursing and medical officer responsibilities