Coroner's Finding: MARKANTONAKIS Stefanos

Contributing factors

• failure to perform adequate physical examination at first ambulance attendance
• failure to take blood pressure measurement despite request, relying on radial pulse alone
• inadequate assessment and dismissal of symptoms as musculoskeletal
• failure to recognise significance of new symptoms (suprapubic and epigastric pain) developing en route to hospital
• failure of ambulance officer to communicate new abdominal pain symptoms to triage nurse at handover
• low triage priority assigned (category 4) based on incomplete handover information
• patient not triaged for imaging or abdominal assessment
• delayed recognition of shock physiology (pallor, sweating, absent pulses) until arrival in ED cubicle
• unsympathetic approach by ambulance officer may have discouraged patient from insisting on hospital transport at first attendance

Coroner's recommendations

1. Establish a system whereby the triage assist nurse has responsibility to chase up the patient case card from the ambulance service and ensure it is obtained before the first half-hourly observations are carried out
2. If the case card reveals that the triage category was inappropriate, or if the case card together with observations suggest inappropriateness, the nurse assist should alter the triage category or ask the triage nurse to reconsider it
3. Ensure that ambulance case cards reliably reach the triage nurse and are reviewed before triage assignment