Coroner's Finding: BALLARD Margaret Dawn

Contributing factors

• misdiagnosis of small bowel torsion as gastroenteritis
• reliance on unreliable history from patient with dementia
• insufficient weight given to severity of collapse
• inadequate period of observation in Emergency Department
• failure to escalate clinical deterioration at psychiatric facility
• no senior clinician review arranged despite complex psychiatric history
• failure to recognize faecal-smelling vomitus as sign of bowel obstruction

Coroner's recommendations

1. Minister for Health should endorse recommendations of the Root Cause Analysis
2. All consumers admitted into a mental health bed must have comprehensive medical examination documented on standard form by mental health treating team within 48 hours of admission
3. Clinical Practice Improvement project undertaken to address sub-optimal medical review of consumers with physical illness in mental health setting, led by senior consultant including psychiatry registrars
4. Mental Health Directorate implement Australian Commission of Safety and Quality in Healthcare recommendations on recognising and responding to clinical deterioration, including criteria for calling rapid response team for medical emergencies
5. Mental Health Directorate Executive discuss concerns regarding Emergency Department's sub-optimal medical assessments with appropriate hospital leadership
6. Senior Medical Consultant lead regular audits of medical assessment of consumers as part of documentation review, with reports to Clinical Governance Committee and Safety and Quality Unit
7. All new registrars to Mental Health Directorate receive documented clear guidelines of responsibilities in admitting consumers, including medical assessment and responding to clinical deterioration