Coroner's Finding: Chadha, Hemant and Battagodage, Sachintha Nandula

Contributing factors

• failure to admit patient despite third ED presentation within 4 days with same complaint
• failure to appropriately investigate new neurological symptoms (numbness, tingling, weakness)
• misattribution of symptoms to anxiety without adequate investigation
• use of pejorative language by paramedics ('man flu', 'drama', 'acopia') that undermined patient confidence
• disrespectful conduct by paramedics toward patient and family
• failure to appreciate significance of haemoptysis in young previously well patient
• failure to order chest x-ray despite haemoptysis
• failure to obtain accurate history of haemoptysis from non-English speaking patient
• failure to review video evidence of haemoptysis provided by patient
• failure to recognise urgency of findings on imaging
• discharge of patient with unexplained mass and active haemoptysis without senior review
• failure to admit patient on re-presentation despite worsening symptoms
• language barrier not adequately addressed with interpreter
• COVID-19 pandemic contributing to reduced admission threshold and inability of family to attend as advocate

Coroner's recommendations

1. Hospital Admission through NALHN ED Procedure be reviewed to require ED Consultants have authority to admit patients who re-present with same symptoms within 72 hours
2. Patients re-presenting within 72 hours must not be discharged without review by senior decision-maker (consultant or senior registrar)
3. Patients re-presenting and referred for admission must not be discharged until documented consultation occurs with referring clinician
4. Procedure allowing referring clinician to formally challenge discharge decision
5. Amended procedure to be audited 12-monthly for compliance
6. All clinicians with admission/discharge authority to be advised in writing and sign confirmation of understanding
7. Uniform procedure across all Local Health Networks for repeat ED presentations within 72 hours
8. SAAS discontinue use of term 'acopia' in all communications
9. Implementation of inclusive language program by SAAS
10. Audit of SAAS complaint policy compliance
11. Development of means to incorporate photographs and videos into patient electronic medical records
12. Copy of Local Team-Based Review Report provided to all staff involved in incident
13. Staff receiving recommendations to be appropriately advised of findings and given opportunity to respond
14. Monitoring of recommendations to ensure appropriate action taken