Coroner's Finding: Fisher, Lynne Patricia

Contributing factors

• failure to apply pneumonia risk-stratification scores (SMART-COP)
• inappropriate assumption of COPD diagnosis without spirometry based solely on smoking history
• setting of dangerously low oxygen saturation targets (88-92%) based on assumed COPD
• failure to insist on hospital admission despite clinical severity
• failure to communicate critical blood results (elevated CRP and WCC) to incoming doctor and patient
• inadequate handover between Dr L. and Dr L.
• failure of night doctor (Dr L.) to review patient when requested by nursing staff
• failure to re-assess patient after significant time elapsed and new medication required
• night doctor remaining in rest room rather than at bedside for patient assessment
• inadequate clinical documentation
• isolated overnight staffing (one doctor for entire hospital ED)
• locum doctor arrangement with poor integration into hospital systems

Coroner's recommendations

1. The Royal Australian College of General Practitioners should release an alert to its members educating them on, and explaining the importance of, the risk scores and 'red flags' relating to community acquired pneumonia
2. SA Health should release an alert to all South Australian Licensed Private Hospitals that treat patients in an emergency setting educating them on, and explaining the importance of, the risk scores and 'red flags' relating to community acquired pneumonia