Coroner's Finding: Williams, Stewart

Contributing factors

• Failure to recognise hypovolaemic shock
• Inadequate monitoring
• Poor documentation of fluid balance and blood loss
• Delayed specialist consultation
• Failure to implement appropriate haemorrhage control measures
• Delayed posterior nasal packing
• Inadequate vascular access
• No definitive plan to investigate bleeding source
• Premature discontinuation of MET response
• Lack of senior clinician involvement in decision-making
• No early consideration of angiography or arterial embolisation

Coroner's recommendations

1. RHH ED to initiate measures to improve fluid balance documentation, including review of current processes, raising awareness amongst ED nursing staff and auditing fluid balance charts
2. RHH Medical Emergency Response (MET and Code Blue) THS Protocol to be revised to give prominence to instruction for escalation to consultant level of any patient who has triggered two MET calls criteria within 24 hours
3. Education package to be included in Tier 2 Mandatory Education, Training and Assessment protocol for all relevant THS South clinical staff regarding escalation process for patients triggering two MET call criteria within 24 hours
4. Actions to raise awareness of clinical staff within ICU and ED regarding importance and clinical accountability for Bedside Clinical Handover requirements and documentation requirements for deteriorating patients
5. Review of Trauma Team Responses Protocol to provide clarity regarding when trauma call can be activated for patients in ED, particularly relating to patients requiring blood transfusion within four hours of presentation
6. RHH to review management protocols for patients suffering facial trauma with ongoing bleeding, including inclusion of senior clinicians, definitive plan to investigate further bleeding, and focusing on airway assessment and cardiovascular stability
7. RHH to review resuscitation protocols for ongoing traumatic haemorrhage