Coroner's Finding: WATKINS Maureen

Contributing factors

• failure to communicate ABG results from intern to supervising registrar
• incomplete clinical handover of test results
• limited supervision of inexperienced intern
• understaffing on medical ward with only one intern and one registrar for over 20 patients
• informal consultation with ICU registrar who was not provided with complete test results
• failure to pursue further diagnostic imaging despite concerning initial ABG result
• no definitive exclusion of pulmonary embolism before intern went off duty

Coroner's recommendations

1. Clinical areas should review local practices to ensure abnormal results (such as ABG tests) are treated as such until proven otherwise by repeat testing
2. Treating teams should seek advice from a consultant neurologist if EEG results report an epileptic encephalopathy picture, with immediate review and consideration for intensive care unit or neurology ward management
3. Medical patients with neuropsychotic or delirium states should be stratified, and high-risk patients should be considered for high dependency management by more experienced staff
4. Consider cohorting such patients in dedicated areas with more experienced staff providing 24-hour cover
5. Consider aligning medical wards as acute care, intermediate care, and long-term care with staffing matched to acuity levels
6. Hospital should review leave arrangements for consultant and registrar medical staff to ensure appropriate and safe cover is provided
7. Address systemic understaffing issues on medical wards to prevent experienced clinicians leaving critical clinical tasks solely to inexperienced interns without sufficient oversight