Coroner's Finding: MCBRIDE Peter James

Contributing factors

• delayed pressure injury risk assessment (not completed within mandatory 8-hour window)
• lack of pressure-relieving mattress despite clear indications for weeks
• inadequate and inconsistent nursing documentation and monitoring
• unnecessary urinary catheterisation without clear clinical indication
• inappropriate bed-rest policy preventing early mobilisation
• high-dose antipsychotics (olanzapine and risperidone) worsening immobility and delirium
• failure to recognise and manage hospital-acquired delirium
• poor inter-physician communication between three treating doctors
• inadequate pain management contributing to behavioural disturbance
• lack of early surgical intervention and family engagement for informed decision-making
• insufficient active pressure mattresses available in hospital

Coroner's recommendations

1. Port Pirie Hospital should substantially increase the number of active pressure mattresses to reflect the demographics of their patient profile
2. SA Health should promulgate to the general practitioner community a reminder that indwelling catheters double the risk of delirium and promote bed-centred care, and that catheter-associated urinary tract infections do not require antibiotic treatment when there is no evidence of more generalised infection
3. This recommendation should be drawn to the attention of the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine