Coroner's Finding: BAIS Jamie Stuart

Contributing factors

• failure to perform lumbar puncture despite clinical suspicion of meningitis
• poor communication between ENT and Infectious Diseases teams
• lack of senior-level consultant coordination
• deprioritisation of lumbar puncture in favour of redundant imaging
• no single clinician or team assuming ownership of patient management
• admission to ENT unit rather than general medical unit despite serious systemic illness
• inaccurate clinical documentation regarding fevers and afebrile periods
• intermittent clinical improvement creating false reassurance
• late involvement of senior clinicians in diagnostic decision-making

Coroner's recommendations

1. Minister for Health to bring to the attention of Chief Executive Officers of all public hospitals the Flinders Medical Centre protocol of March 2010 relating to ENT patients with suspected meningitis
2. Chief Executive Officers of all public hospitals should consider whether such a protocol should be employed in their institutions
3. Education sessions for junior medical staff regarding performance, uses and interpretation of lumbar punctures
4. Memorandum to all medical staff highlighting the importance of lumbar puncture in patients with any clinical suspicion of meningitis, with specific guidance on atypical presentations where classic signs such as neck stiffness may be absent
5. ENT units should require daily consultant telephone review with structured handover of all patients regardless of consultant assigned
6. Implementation of structured shift-to-shift handovers with clearer leadership, multidisciplinary participation, and consideration of pathology and radiology data
7. Patient handover procedures to include family involvement
8. Implementation of standards for recognition of and response to the deteriorating patient, including documentation thresholds and escalation triggers