Coroner's Finding: VELT Hank Jakob

Contributing factors

• failure to recognise significance of acute MI on ECG
• failure to make MET call despite clear ECG findings
• inadequate nurse training on ECG interpretation and risk response
• inadequate hospital policies for managing chest pain in non-cardiac wards
• failure of on-call doctor to ask what ECG interpretation stated
• failure of ECG fax transmission
• patient left unattended despite suspected MI
• absence of cardiac monitoring in general ward
• poor communication between nursing staff and medical officers

Coroner's recommendations

1. Amend Medical Emergency Team Calling Criteria to divide 'New or unrelieved chest pain' into two criteria: 'New chest pain (whether or not relieved)' and 'Unrelieved chest pain'
2. Add criterion 'An ECG taken in the absence of a doctor asserts, in the written interpretation, heart attack, infarct or myocardial infarction, or ST elevation' to MET calling criteria
3. If full implementation of above recommendations not achieved, develop and implement a Chest Pain Policy for nurses caring for patients not subject to cardiac monitoring including: immediate notification of medical officer, continuous observation, defibrillator availability, ECG conduct, staff training, and policy monitoring
4. Implement programmed training or refresher training of clinical staff in management of clinical risks
5. Review policies and procedures relating to student nurses to ensure appropriate supervision and prevent them bearing responsibility for clinical tasks or decision-making