Finding into death of Marlene Kenny

Contributing factors

• Initial presentation misdiagnosed as panic attack without investigation of hypoxia
• Hypoxia not investigated; no chest X-ray or senior assessment
• Patient discharged without documented medical plan or follow-up review
• ECG performed but not adequately interpreted
• Significance of admission hypoxia on second presentation not recognised
• Limited documentation of medical and nursing assessments on second presentation
• Complexity of presentation not recognised - paradoxical stroke from patent foramen ovale with right-to-left shunt not suspected
• Failure to escalate for early transfer while patient stable
• Transfer delayed over 9 hours due to poor communication between hospital and ambulance services
• Initial transfer request marked 'routine' rather than 'time critical' despite deteriorating condition
• RAV controller did not clarify clinical significance of 'another episode'
• RAV did not notify hospital of likely delays in air transport
• Limited air ambulance resources due to other urgent cases and bushfires
• Ineffective bed coordination requiring multiple phone calls and significant time
• Environmental factors: major bushfires affecting air transport visibility
• Geographic isolation: 400km from nearest tertiary centre

Coroner's recommendations

1. Develop and implement guidelines for reportable observations and include as prompts on observation charts
2. Develop key performance indicators on completion of medical documentation reportable to Director of Medical Services and Clinical Risk Review Committee
3. Develop key performance indicators on completion of nursing documentation reportable to Director of Nursing and Clinical Risk Review Committee
4. Develop and implement guidelines for recall or follow-up of patients discharged without medical review
5. Hospital, RAV and AAV services work collaboratively to develop and implement standardized structured clinical handover process including options for providing information on maximum hours transfer can take and maximum time patient can be outside hospital
6. Systems to provide transferring agency with expected timeframe for transfer and notify of changes in condition or expected timeframes
7. Develop new classification guideline for transfer requests with expanded options beyond routine and time critical
8. RAV review operations centre guidelines for contingency planning for transport arrangements
9. RAV review operations centre policies and procedures regarding requesting aircraft for routine and time critical requests
10. RAV develop and implement process to audit clinical decision making in operations centre
11. Hospital develop guidelines for optimum time to transfer high risk patients considering location and time to activate resources
12. Implement evidence-based risk screening tool for management and transfer of patients with transient ischaemic attacks
13. Review Medical Officer orientation program to include circumstances where they may have to escort patients and time-effective means of arranging beds in higher level facilities
14. Amend neurological observation charts to include area for recording oxygen saturations and oxygen delivery
15. Develop and implement stroke/transient ischaemic attack care pathway
16. Department of Human Services consider developing process for facilities to determine bed availability through central point for urgent transfers
17. Hospital and ambulance service staff be reminded of importance of patients, families and carers receiving information and support throughout care delivery