Mrs MDF - Non-inquest findings

Contributing factors

• failure to recognize clinical deterioration despite metabolic acidosis and haemodynamic instability
• lack of direct communication between Consultant Surgeon and Consultant Intensivist
• absence of clear written escalation parameters and management plan
• junior medical staff (Dr SK and Dr NA) did not appreciate patient's deteriorating condition
• neither Consultant physically reviewed the patient after initial admission to ICU
• delay in surgical intervention - patient became moribund before operation
• lack of contemporaneous medical documentation by senior staff
• inadequate supervision of junior staff by senior consultants
• misinterpretation of blood gas results showing marginal lactate reduction despite worsening metabolic acidosis

Coroner's recommendations

1. All medical officers in the surgical division be reminded of professional standards and expectations of the Gold Coast Hospital and Health Service, with presentation of de-identified case at departmental meetings for learning
2. Robina ICU to operate as extension of level 6 ICU at Gold Coast University Hospital
3. Cross-campus ICU Director with Deputy ICU directors at each site to be appointed
4. Implementation of written protocols/processes outlining deterioration criteria and escalation triggers for conditions like ischaemic bowel to assist junior staff in knowing when to call senior staff
5. Requirement for documented Consultant-to-Consultant discussion and clear management plans with specific escalation parameters before admission to ICU for high-risk conditions
6. Emphasis on importance of senior clinician personal review of complex cases and contemporaneous medical documentation