Enid Patricia Hiddle - Non-inquest findings

Contributing factors

• Undiagnosed acute kidney infection (pyelonephritis)
• Kidney infection not detected despite hospital requests for urinalysis in August and September 2016
• Poor documentation of urinalysis results at aged care facility
• Lack of physical examination by treating GP at final review despite two-week absence
• No vital signs or observations recorded at final review
• Treating GP unavailable for extended period
• Lack of communication between hospital and primary care
• Rapid functional decline not adequately addressed
• Multiple falls not investigated for underlying cause
• Severe coronary artery disease (80-90% blockage)
• Dehydration and malnutrition

Coroner's recommendations

1. Aged care facilities should maintain formal codified policies and procedures for documenting all urinalysis results (positive and negative)
2. Staff training in urinary tract infection identification, testing, and documentation should be mandatory and ongoing
3. General practitioners should perform physical examinations and record vital signs, particularly when resuming care after absence
4. Improved communication protocols between hospitals and general practitioners regarding follow-up investigations
5. Clear escalation pathways when residents show signs of acute illness or functional decline
6. Documentation of all clinical assessments and test results in aged care facilities