Coroner's Finding: ATKINS Stephen Robert

Contributing factors

• four-hourly monitoring regime inadequate for high-dose opioids
• combined use of multiple opioid medications without clear dosing intervals
• prescription of slow-release oxycodone (OxyContin) in combination with fast-acting opioids
• failure to escalate care via RaDAR protocols despite red and purple zone triggers
• inadequate sedation assessment—zero scores recorded throughout despite clinical evidence of respiratory depression and excessive drowsiness
• poor documentation of vital signs removing essential diagnostic information
• oxygen desaturations not recorded on observation chart
• failure to investigate oxygenation events despite desaturation to 88-91%
• insufficient knowledge and training of nursing staff regarding opioid toxicity signs
• failure to refer to Acute Pain Service despite ineffective pain control and high opioid doses
• lack of clear written directions regarding minimum intervals between opioid doses
• nursing staff not recognising clinical significance of family observations of respiratory depression and vomiting
• consultant conducting cursory review without reading medication chart or progress notes
• calculated morphine equivalent dose in error without affecting prescribing decision
• absence of continuous monitoring or one-hourly vital sign checks after peak effect times
• decision not to wake patient for 5am observations despite deteriorating condition

Coroner's recommendations

1. Initiatives commenced and developed by the South Australian Local Health Network be urgently implemented in their entirety
2. Practice of on-call specialist consultants being rostered to cover dual specialities be ceased
3. Committee or body be established to review process of information sharing amongst medical and nursing staff with focus on handover process and use of progress notes as primary information source
4. Proposed changes to education and training of medical and nursing staff about dangers of opioid medications be repeated at regular intervals by implementation of mandatory refresher courses
5. Implementation of new SALHN guidelines for appropriate prescribing, administration and documentation of opioids
6. Introduction of Pain Resource Nurses and Acute Pain Service presentations to medical interns and nursing staff
7. Development and use of Acute Pain Management Chart requiring sedation, respiratory rate, pain and functional activity assessments at time of opioid administration and one hour later
8. Medical officers provided with quick reference lanyards regarding dosing, monitoring and management of respiratory depression
9. Enhanced education on correct graphing and documentation on RaDAR chart with focus on recognition of clinical deterioration
10. Review of nursing curricula regarding knowledge and training in opioid medications and respiratory depression recognition
11. Consideration of use of continuous monitoring equipment or hourly vital sign checks after opioid administration peak effect times