Coroner's Finding: CAMPANELLA Cosmo Joseph

Contributing factors

• tracheostomy tube occlusion from tracheal secretions
• inadequate monitoring and documentation of tracheostomy care on general ward
• transfer to general ward (Ward S5) with questionable nursing expertise in tracheostomy care
• possible inadequate frequency of tracheostomy suctioning
• lack of continuous oximetry monitoring
• poor nursing care documentation
• possible deteriorating neurological state prior to transfer not fully appreciated
• possible occult sepsis with increased secretions

Coroner's recommendations

1. Tracheostomy patients whose conscious state is significantly impaired should be subject to constant oximetry monitoring, regardless of setting (ward, High Dependency Unit, or Intensive Care Unit)
2. Nursing staff should maintain detailed contemporaneous documentation of all tracheostomy care performed, not relying on retrospective accounts
3. Hospital should ensure proper orientation and training of nursing staff on general wards regarding tracheostomy care standards and competency
4. Root cause analysis inquiries should be conducted promptly following adverse events, with clear identification of participants and findings reviewed with relevant stakeholders
5. Hospitals should be transparent about section 64D inquiry processes and should not inappropriately invoke confidentiality provisions to withhold information from coronial inquiries