Coroner's Finding: Smith, Molly Jessie

Contributing factors

• failure to diagnose urinary tract infection progressing to kidney infection
• misdiagnosis of respiratory infection instead of kidney infection
• failure to order urgent blood tests and imaging
• inappropriate antibiotic selection and route (oral instead of intravenous)
• failure to transfer to hospital for acute medical care
• delay in recognition of clinical deterioration despite vital sign abnormalities
• failure of nursing staff to escalate concerns to senior clinicians
• inadequate policies for escalation of care in acute medical deterioration
• lack of 24-hour on-site medical cover
• telephone advice service (GP Assist) without direct clinical assessment

Coroner's recommendations

1. RFC should modify the Adult Observation and Response Chart to incorporate clear instructions regarding appropriate instances for invoking GP Assist service during after-hours periods, with reference to acute/non-acute presentations and Tiers 1-4
2. RFC should provide ongoing training of nurses in managing acute medical conditions including procedures for liaison with consultants or medical officers, recording of escalation, use of GP Assist service, and training in use of the Chart
3. RFC should conduct a review of procedures for supervision of medical practitioners holding conditional registrations, including selection and training of supervisors and recording and retention of all supervision documentation
4. RFC should implement a written policy and system to ensure persons admitted who are incapable of giving informed consent are only admitted, treated and continue residence with substitute consent of a legal guardian appointed under Guardianship and Administration Act 1995 or pursuant to a power or order under Mental Health Act 2013