PS - Non-inquest findings

Contributing factors

• Premature discharge after inadequate diagnostic workup
• Failure to recognise and act on abnormal vital signs and Q-ADDS scores
• Inadequate length of stay for assessment and monitoring in acute heart failure
• Incorrect documentation and misinterpretation of ECG findings
• Mistaken assumption about cardiology follow-up timing
• Poor discharge planning and communication with general practitioner
• Absence of weight monitoring and fluid balance charts
• Failure to involve pharmacy in discharge planning
• Non-compliance with Q-ADDS escalation protocols
• Inadequate documentation of clinical decision-making
• Daughter's concerns not escalated or documented
• No GP follow-up appointment arranged prior to discharge
• Staffing issues including use of locum and junior medical officers without adequate supervision
• Lack of clarity around after-hours escalation procedures

Coroner's recommendations

1. Ensure all clinical staff receive education and training in the use of early warning and response system tools (CWET and Q-ADDS) and escalation of care
2. Frequency of clinical observations and recording of pain levels be consistent with acuity and clinical condition
3. When rapid response required for Q-ADDS score 'E' after-hours, immediately call Medical Emergency/Code Blue, mobilise on-call staff and contact QCC
4. Check accurate completion of observation forms and appropriate escalation at each bedside safety check
5. Use progress notes to record comprehensive entries on interventions in response to vital signs
6. Provide regular reports on trended aggregate incident data and outcomes of clinical case reviews at ward meetings
7. Require nominated scribe to record all details on Resuscitation Observation Form during cardiac arrests
8. Scribes must record names and positions of all clinical staff attending Medical Emergency calls
9. Incorporate criteria for triggering Medical Emergency calls in Clinical Procedure documents
10. All nursing staff to complete competencies for basic life support with regular scenario-based learning
11. Nursing staff education on non-invasive ventilation using BiPAP
12. Each HHS facility to provide Clinical Coach or experienced assessors for formative and summative assessments
13. Purchase high pressure nasal prongs for BiPAP machines
14. Develop HHS Non-Invasive Ventilation BiPAP/CPAP procedure and Clinical Competency Tool
15. Inform medical staff that all patient assessments and procedures must be documented comprehensively
16. Discharge summaries must be provided within 24 hours of patient discharge
17. Require all clinical staff to attend training on Patient Flow Manager System and discharge planning
18. Ensure family members are offered opportunity to be involved in discussions and decisions about treatment and discharge
19. Implement Ryan's Rule for escalation of patient-carer concerns
20. Clinical staff to administer IV morphine with extreme caution in patients with pre-existing respiratory depression and renal impairment, commencing with lower doses (2mg initially, then 0.5-1mg increments)
21. Develop new orientation program for locum medical officers including education on early warning tools and clinical escalation
22. Appoint permanent Director of Medical Services and recruit permanent medical staff
23. Improve triaging of emergency presentations and management of patients seeking discharge against medical advice
24. Develop local Medical Emergency procedure and flow chart for patients meeting criteria