Coroner's Finding: MAYELL Edward John

Contributing factors

• Delayed recognition of pneumonia diagnosis
• Failure to communicate urgent radiological findings by telephone
• Misdiagnosis of community-acquired pneumonia as aspiration pneumonia
• Incorrect antibiotic therapy targeting aspiration rather than atypical organisms
• Failure to chase radiological results while patient remained at hospital
• Delayed administration of antibiotics (2.5 hours after admission)
• Inappropriate triaging as Category 4
• Inadequate consideration of low blood pressure and signs of shock
• General practice closed on critical diagnostic day
• Lack of vital sign monitoring and recording
• Perpetuation of diagnostic error between clinicians

Coroner's recommendations

1. SA Health, Country Health SA and South Australian Ambulance Service establish clear mutual understanding regarding appropriate hospital transfers in South-East region
2. Millicent Hospital implement procedures for: identification of deteriorating patients; regular clinical observations and recording thereof; appropriate triaging processes considering existing diagnoses and presentations; immediate communication of important radiological results; routine colour-coded observation charts in Emergency Department; robust processes for rapid response to abnormal vital signs
3. SA Health consider state-wide sepsis identification and treatment project similar to New South Wales model directed at all clinicians
4. Benson Radiology remind all staff that unexpected, urgent and sinister findings require immediate telephone communication to referring practitioner, particularly pneumonia identified in contexts where pneumonia is not the suspected diagnosis
5. Beachport Medical Centre ensure robust and reliable means to draw urgent radiological and pathological results to attention of available medical practitioners
6. Beachport Medical Centre establish clear understanding with Millicent and Mount Gambier hospitals regarding transmission of important patient information
7. Picture Archival Communications System (PACS) be immediately installed at Millicent Hospital for electronic radiological transmission
8. Medical practitioners be reminded to independently re-evaluate patient differential diagnosis whenever different practitioner examines patient