Mrs R-W - Non-inquest findings

Contributing factors

• failure to access prior medical records documenting previous SIADH diagnosis
• lack of awareness that pre-existing chronic hyponatraemia was related to SIADH
• prescription of citaprolam in setting of pre-existing hyponatraemia
• substitution with duloxetine which also causes hyponatraemia
• delayed or missed blood test on 17 November
• failure to implement strict fluid restriction despite documented hyponatraemia
• inadequate escalation of clinical deterioration on 18 November (reduced consciousness, hypoxia)
• failure to use early warning response observation (EWARS/Q-ADDS) tool appropriately
• poor communication within emergency department team regarding management plan
• unclear role and decision-making authority of non-credentialed private hospital consultant in public hospital setting
• inadequate nursing handover using SBAR tool
• insufficient documentation of observations and management decisions in emergency department
• delayed admission to medical team for inpatient management

Coroner's recommendations

1. Develop and implement mandatory criteria for escalation to a Senior Medical Officer and higher within the Emergency Department
2. Review the inter-hospital transfer process between the small metropolitan private hospital and the metropolitan public hospital, with a protocol endorsed by both facilities to clarify clinical responsibility and management continuity
3. Develop a local hyponatraemia procedure/protocol
4. Provide education and training to nursing staff about use of the Emergency Q-ADDS (Early Warning and Response Observation) tool
5. Conduct case discussion with Emergency Department staff for clinical education purposes
6. Implement formal processes for emergency admissions to review all medical record requests and ensure prior records are retrieved in a timely manner
7. Update Current Clinical Alert forms to indicate what paper records exist for patients
8. Ensure all acute inpatients have minimum 4th hourly observations documented on Q-ADDS unless otherwise specified by admitting consultant
9. Reinforce with Visiting Medical Officers and staff that Medical Emergency Team calls must be activated when patients meet MET call criteria
10. Implement structured handover processes using SBAR tool within emergency department shifts
11. Clarify that small metropolitan private hospital consultants should only provide advisory input for patients admitted to the metropolitan public hospital, with full clinical responsibility resting with public hospital medical staff