Non-inquest findings into the death of Mr H.

Contributing factors

• inadequate bowel care and management in RACF
• failure to recognize faecal overflow as faecal impaction rather than normal bowel function
• lack of abdominal assessment after 4 March 2022 despite evidence of faecal loading on 9 March
• missed opportunities to escalate management of constipation between 4-27 March 2022
• unclear and undocumented medical escalation pathways between nursing and medical staff
• inadequate laxative regimen in patient on opioid analgesia
• shift-by-shift bowel assessment focused on stool type classification, shifting focus away from constipation
• loss of advance health directive information during transfer
• lack of central clinical oversight for bowel care
• poor communication and coordination between visiting GP, geriatrician, and rural hospital physicians

Coroner's recommendations

1. Implement improved bowel management practices in RACFs including new bowel charts and education programs
2. Ensure nursing staff receive training on how to recognize and appropriately chart stools and bowel movements, distinguishing faecal overflow from normal bowel function
3. Establish clear, documented medical escalation pathways between nursing and medical officers with specified expectations and availability
4. Implement regular review of bowel charts by medical officers for unwell patients
5. Ensure advance health directives and resuscitation plans are visible to all health professionals and appropriately transferred during patient handover
6. Provide education on medications and medical conditions that contribute to bowel problems, particularly in patients on opioid analgesia
7. Implement regular abdominal assessment for patients with constipation risk factors