Coroner's Finding: FALANGA Salvatore

Contributing factors

• trauma to intercostal vessels during pleural tap procedures causing haemothorax
• inadequate fluid resuscitation during early hours of 8 February 2003
• delayed recognition of severity of bleeding and hypovolaemia
• failure to arrange ICU consultation during weekend deterioration
• lack of central venous monitoring to guide haemodynamic management
• absence of senior clinician review overnight on 8 February
• inadequate communication: Dr G. not notified of weekend deterioration
• high-risk patient with pre-existing renal impairment and diabetes managed in non-ICU setting
• no continuous intensive care supervision of HDU at that time

Coroner's recommendations

1. Implementation of daily ICU review for HDU patients (note: subsequently implemented at TQEH from 2005 onwards)
2. ICU consultation should be arranged for complex high-risk patients with acute deterioration, particularly those with pre-existing renal impairment experiencing hypotensive episodes
3. Senior clinician should be directly informed of significant patient deterioration, even outside normal business hours, particularly when the patient has multiple comorbidities
4. Use of central venous pressure monitoring and pulmonary artery catheters to guide haemodynamic resuscitation in patients with complex medical conditions and acute bleeding
5. More aggressive approach to fluid resuscitation in early phase of recognised bleeding, with target systolic blood pressure >100 mmHg in elderly patients with renal compromise
6. Junior doctors should recognise limitations of their experience and escalate complex cases to senior registrars and on-call consultants without delay
7. Ward-based management should be considered inadequate for patients requiring intensive monitoring of fluid balance and haemodynamics; ICU or high-dependency care should be accessed promptly