Non-inquest findings into the death of Donald Richard Gunthorpe

Contributing factors

• Broad-range anticipatory prescribing of end-of-life medications on admission without clear clinical guidance
• Inadequate documentation of symptom assessment and medication efficacy
• Lack of clear clinical justification for dose escalation from 5mg to 10mg morphine
• Nursing staff commencing medications at highest dose rather than lowest dose range
• Insufficient communication between GP and nursing staff regarding dose escalation
• Incomplete case conferencing documentation regarding end-of-life pathway commencement
• Inadequate progress notes and clinical record-keeping by clinical nurse consultant

Coroner's recommendations

1. RACF and healthcare facilities should review systems and processes around the commencement of end-of-life care to ensure they align with best practice guidelines
2. Build checks into systems to audit whether decisions made about care recipients' care are based on documented signs or symptoms consistent with clinical evidence
3. Review and reinforce whistleblower policies and training for staff across aged care facilities
4. Continue close monitoring of RACF compliance with end-of-life care standards
5. Implement safeguards when prescribing and administering end-of-life medications including: (a) avoiding broad anticipatory dose ranges; (b) providing explicit written guidance on starting doses; (c) documenting clinical justification for dose escalation; (d) requiring comprehensive two-hourly symptom assessments; (e) mandating evaluation and documentation of medication efficacy
6. Require GPs to maintain clear contemporaneous notes in facility computer systems and comprehensive personal notes for after-hours consultation
7. Ensure case conferences regarding end-of-life pathway commencement are fully documented and occur prior to medication commencement
8. Implement regular two-hourly symptom assessment documentation as recommended by the Palliative Approach Toolkit
9. Establish clearer communication protocols between GPs and nursing staff regarding dose escalation decisions in end-of-life care