Barichello, Daniele Antony - Non-inquest findings

Contributing factors

• Delay in surgical intervention from Friday to Sunday due to unavailability of endoscopic equipment
• Failure to escalate deteriorating patient to intensive care despite worsening neurological symptoms
• Management in general surgical ward with only two-hourly neurological observations instead of continuous ICU monitoring
• Use of narcotic analgesia (tramadol) masking signs of increasing intracranial pressure
• Neurosurgeon did not examine patient in person before making decision to reschedule surgery
• Lack of documentation regarding decision-making and clinical review on 5-6 December
• Decision not to proceed with Saturday night emergency surgery despite documented clinical deterioration

Coroner's recommendations

1. Visiting Medical Officer (VMO) neurosurgeons should confirm availability of non-routine surgical equipment prior to offering procedures reliant on such equipment to patients
2. VMO surgeons should make direct arrangements for loan equipment when necessary and should not delay surgery based on equipment unavailability when clinical deterioration occurs
3. Patients should not be offered procedures involving non-routine equipment unless it has been determined that the equipment can be obtained without material delay
4. VMO surgeons should be advised about the benefits of early referral of unstable patients to intensivists in Intensive Care for monitoring
5. Nursing staff should be reminded they are empowered to discuss treatment options and escalation concerns with VMOs
6. Development of clear clinical pathways for recognition and escalation of patients with symptoms of raised intracranial pressure
7. Establishment of alternative clinical pathways allowing nursing staff to initiate transfer to ICU when they consider it necessary (note: this recommendation was disputed by consulting neurosurgeon)
8. Neurosurgical wards should ensure continuous monitoring and observation protocols for patients at risk of rapid neurological deterioration
9. Review of policies regarding narcotic analgesia use in neurosurgical patients—should be restricted to ICU/HDU settings with continuous monitoring
10. Regular training and communication with nursing staff about escalation responsibilities and empowerment to raise clinical concerns