Non-Inquest findings into the death of Ms G
Deceased
Ms G
Demographics
76y, female
Date of death
2024-05-02
Finding date
2025-10-24
Cause of death
Head injury comprised of subdural haematoma, subarachnoid haemorrhage with brain swelling and associated complications
AI-generated summary
A 76-year-old woman died from complications of a severe head injury sustained in a motor vehicle collision. She was initially managed conservatively at a regional hospital, but her condition deteriorated markedly at 9pm with signs of increased intracranial pressure. Critical delays occurred in escalating and transferring her to a neurosurgical centre. The regional hospital's junior doctor failed to escalate deterioration at 10pm, and the tertiary hospital's junior registrar underappreciated severity and did not escalate to a consultant. Systemic barriers included difficulty contacting the tertiary hospital switchboard and reluctance of junior staff to challenge tertiary advice. Earlier recognition of deterioration and direct consultant-to-consultant communication could have enabled timely transfer before irreversible neurological damage occurred.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Delay in interhospital transfer to tertiary neurosurgical centre
- Failure of junior medical officer to escalate deterioration at initial assessment at 10pm
- Underappreciation of severity by tertiary hospital neurosurgical registrar
- Failure to escalate to tertiary hospital consultant out of hours
- Reticence of junior staff to challenge tertiary hospital advice
- Missed opportunity for local consultant discussion and escalation
- Difficulty contacting tertiary hospital switchboard for consultant escalation
- Absence of further internal escalation within regional hospital following denied transfer request
Coroner's recommendations
- Joint Grand Rounds presentation by RBWH and Rockhampton Hospital highlighting difficulties and solutions including challenges for regional facilities, importance of escalation after-hours, empowerment of junior doctors to speak up for safety, and reiteration of doctor-to-doctor discussion importance for time-critical patients
- Review of HENRI system to add field prompting regional doctors to advise of logistical issues for inter-hospital transfers
- Strengthen escalation processes in deteriorating patient situations through existing recommendations and review of barriers and culture issues
- RBWH to undertake Morbidity & Mortality analysis on events prior to patient arrival, focusing on Rockhampton ED episode and all transfer communications
- Address RBWH switchboard difficulties in putting through calls to consultants on call
Full text
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