Mrs NSM - Non-inquest findings

Contributing factors

• delay in recognising arterial injury and haemopneumothorax
• use of standard single response system observation chart instead of 'track and trigger' tool
• failure to initiate MET call at appropriate time (3:00 pm)
• medical reviews conducted by staff without appropriate speciality skills
• failure to conduct chest X-ray when clinically indicated
• blind subclavian punctures without prior imaging guidance
• multiple venous punctures during pacemaker insertion
• inadequate senior medical staff involvement in post-operative care
• delay in identifying significant blood loss
• delayed commencement of blood transfusion
• difficulty accessing appropriately skilled staff out-of-hours for chest drain insertion
• pain during procedure misinterpreted as osteoarthritis rather than vascular injury
• digital pressure rather than cauterisation for bleeding control
• misinterpretation of venogram findings
• retrospective documentation in patient records

Coroner's recommendations

1. Review, implement and evaluate locally developed cardiac-specific Q-ADDS chart (track and trigger observation scoring system) in cardiology units
2. Refer possibility of cardiac-specific Q-ADDS to State-wide 'Recognition and Responding to Clinical Deterioration in Acute Healthcare' group for pilot trial
3. Amend 'Clinical Pathway Pacemaker/AICD' to include indications of arterial injury as per recommendations of Interventional Cardiologists
4. Establish evidence-based best practice workplace protocol for implementing ultrasound-guided cannulation of subclavian vein instead of landmark method prior to repeated subclavian arterial puncture
5. Implement quality improvement plan to address retrospective documentation in patient records
6. Develop clear and definitive process for accessing appropriately skilled Medical Officer out of hours for intercostal catheter insertion
7. Review allocated resourcing and processes for out-of-hours medical imaging (mobile chest X-ray) availability
8. Conduct regular medico-legal and Patient Care Plan audits with discussion at departmental meetings