Coroner's Finding: Lavoipierre, Andre Marc

Contributing factors

• failure to call ambulance despite clear clinical indicators
• worker did not receive handover of morning events
• worker did not read case notes at start of shift
• failure to recognise hypovolemic shock presenting as dizziness
• failure to escalate to emergency services
• lack of specificity in Richmond Fellowship policies on medical emergencies
• deficient communication between staff
• delayed medical intervention (after-hours GP service rather than emergency response)
• patient on mental health treatment order with impaired decision-making capacity but worker relied on patient's agreement to refuse ambulance

Coroner's recommendations

1. That policies and procedures at Richmond Fellowship be updated to provide sufficient specificity regarding medical emergencies (subsequently implemented with Health Direct consultation requirement)
2. That vital signs monitoring be implemented as standard (respiratory rate, oxygen saturations, resting pulse rate, temperature) to be communicated to Health Direct
3. That staff training be improved in identifying and responding to physical health issues
4. That communication protocols between staff be improved, including mandatory handovers and case note review at start of shifts
5. That emergency response procedures be clarified so that decision-making authority regarding ambulance calls is not delegated to vulnerable patients with impaired decision-making capacity