Non-inquest findings into the death of Mr S

Contributing factors

• Atypical presentation of primary varicella zoster infection (chickenpox) not recognised on initial assessment
• Rash not identified as varicella zoster due to atypical appearance (blanched, maculopapular, linear erythematous rather than typical vesicular)
• Failure to review patient at 1:30am when vital signs deteriorated (tachycardia, hypoxia)
• Delay of approximately 3 hours in commencing intravenous antibiotics
• Difficulty arranging timely inter-hospital transfer to tertiary centre due to bed availability and lack of unifying diagnosis
• Delay of approximately 5 hours in transfer from Redland Hospital to Princess Alexandra Hospital
• System issues with inter-hospital transfer process for undifferentiated critically ill patients
• PAH clinical teams initially declining to accept patient due to bed capacity constraints

Coroner's recommendations

1. Senior Medical Officer Clinical Governance to work with Chief Operating Officer and stakeholders from all directorates to develop a service redesign/clinical quality improvement program to develop a robust agreed process for escalation and transfer of the undifferentiated unwell patient
2. Implementation of updated Interhospital Transfer Procedure ensuring that transfer of critically ill patients will not be delayed due to bed availability at receiving facility
3. Publication of patient distribution case review guidelines to improve governance and review of patient care impacted by delayed escalation and inter-hospital transfers
4. Establishment of Reference Group to support implementation of guidelines across health service
5. Continued education delivery regarding sepsis pathway to junior doctors rotating through Emergency Department and Registrar Education
6. Case presentation at Clinical Incident Review Committee and Departmental Mortality and Morbidity meetings
7. Development of ICU beds at Redland Hospital to allow on-site critical care assessment and direct ICU-to-ICU transfers
8. Widespread sharing of de-identified findings with clinicians to raise awareness of atypical varicella presentation, need for early sepsis intervention, and inter-hospital transfer issues