Coroner's Finding: Pedler, Anne Helen

Contributing factors

• delay in initiating anticoagulation or thrombolytic therapy
• delay in CT pulmonary angiogram due to absent pathology results
• unfamiliarity with electronic ordering system (TrakED)
• lack of radiographer on-site overnight
• failure to call pathologist for urgent out-of-hours testing
• failure to call radiographer regarding urgent imaging request
• absence of previous health records
• inadequate medical staff orientation to emergency department protocols
• inadequate ED orientation regarding escalation criteria
• nursing staff deficiency (5 staff short)
• ED at capacity with 25 patients
• patient ramped for 8 hours without bed availability
• severity of illness underestimated

Coroner's recommendations

1. Review of ED orientation program for new medical staff to include roles and responsibilities of clinicians for patients in transfer of care delay
2. Process for calling pathologists for urgent testing, both within and out of hours, be documented in a protocol or guideline and be included in new medical staff orientation to the emergency department
3. Consider the feasibility of 24-hour on-site medical imaging practitioners at the hospital
4. Emergency department to review medical staff orientation to include key work processes such as how to request urgent diagnostic tests out of hours
5. Emergency department staff responsible for calling the on-call consultant when escalation criteria are met receive refresher education on these requirements
6. Provide read-only access to TrakED to all medical imaging staff to assist with workflow and to ensure all requests are actioned in a timely manner
7. Protocol or guideline be developed by the pathology department that outlines requesting processes, both within and out of hours, for urgent and non-urgent pathology testing
8. After-hours medical imaging request protocol be updated to include differing referral methods (paper-based or electronic) and follow-up requirements for requesting urgent diagnostic radiological tests
9. THS should address ramping and propose solutions to resolve this issue