Mr RR - Non-inquest findings

Contributing factors

• Failure to escalate clinical deterioration to senior medical officer
• Continuation of bowel preparation despite multiple vomiting episodes
• Lack of documentation by Ward Call doctors
• Absence of clinical guidelines for inpatient bowel preparation
• Patient admitted to outlying ward rather than specialty unit
• Delay in commencing bowel preparation (6.5 hour delay in Transit Care Hub)
• Failure to recognise intolerance to bowel preparation
• Multiple junior doctors providing fragmented care without senior oversight
• Abnormal vital signs on admission not appropriately acted upon
• Absence of Rapid Response Team activation despite meeting code criteria

Coroner's recommendations

1. Review of patient admission process in Transit Care Hub to facilitate inpatient bed admissions for bowel preparation by 3:00pm
2. Development of clinical guideline for inpatient administration of colonoscopy bowel preparation incorporating escalation processes when administration deviates from expected pathway
3. Ensure patients requiring inpatient bowel preparation are routinely admitted to the home specialty ward where possible
4. Escalation of concerns about failure to escalate clinical deterioration with targeted education for junior medical staff on appropriate actions when patients deviate from planned clinical course
5. Implementation of rapid response criteria alerts in electronic medical records with education for all clinicians on alert recognition and appropriate actions
6. Emphasis on proper patient selection for colonoscopy with lower threshold for procedure postponement or cancellation in older, fragile patients with abnormal vital signs