FD - Non-inquest findings

Contributing factors

• failure to recognise sepsis in rural hospital setting
• failure to review and act on pathology results (elevated lactate, WCC, CRP)
• failure to escalate hypotension and clinical deterioration
• delayed antibiotic administration (6 hours post-presentation)
• inadequate PEG complication recognition and management guidance in rural facilities
• absence of systematic use of sepsis pathway screening tool
• delayed surgical team acceptance of transfer
• delayed consultation with retrieval services
• inadequate patient preparation and stabilisation prior to transfer
• inappropriate transfer escort selection (single paramedic with nurse escort for unstable patient)
• limited handover documentation and communication
• failure to utilise Q-ADDS chart appropriately to trigger escalation
• incomplete nursing orientation of casual staff
• suboptimal SBAR handover use

Coroner's recommendations

1. Update HHS Gastrostomy Tube Management Procedure and PEG Careplan to incorporate: indications for discontinuing PEG feeds when complications suspected; indications for contacting on-call gastroenterologist after hours; bumper position checking and documentation requirements; device securing guidance; indications for considering entry into Sepsis Pathway with functional hyperlinks
2. Improve compliance with Q-ADDS documentation, clinical handover and clinical escalation requirements
3. Review and improve use of SBAR communication during medical, nursing and QAS handovers
4. Review interhospital transfer procedure and associated flowcharts and checklist to incorporate: consideration of Q-ADDS stability/trending in hours prior to transfer; upgrade sepsis criteria from 'moderate' to 'high dependency' risk score in escort selection guide; require RSQ consultation for all sepsis cases prior to transfer
5. Ensure casual and enrolled nurses receive mandatory orientation covering recognition and management of deteriorating patient, sepsis pathway, clinical handover and clinical escalation within 4-8 weeks of employment
6. Establish formal procedure for Level 1 Clinical Service Capability Framework facilities to access medical back-up when road transfer of critically ill patient required
7. Ensure HHS InterHospital Transfer Patient Checklist is completed prior to all transfers
8. Enhance awareness of PEG care requirements and complications in rural facilities
9. Promote implementation and compliance with Adult Sepsis Pathway across all HHS facilities