Finding into death of Broughton Hall Inquest

Contributing factors

• Delayed notification to Department of Health (April 7 to April 10)
• Inadequate infection control protocols and policies not accessible to staff
• Failure to obtain faecal samples early in outbreak course
• Delayed identification of Salmonella pathogen (identified April 13)
• Failure to communicate positive Salmonella results to treating doctors and nursing staff
• Confusion about roles and responsibilities between doctors and public health agencies
• Lack of clarity about who directs and performs faecal testing
• Poor communication between nursing staff and treating medical practitioners
• Assumption outbreak was viral rather than bacterial
• No written documentation of pathology results provided to clinical staff
• Failure to notify ambulance and receiving hospital of Salmonella diagnosis on patient transfer

Coroner's recommendations

1. Mandatory notification of gastroenteritis outbreaks in aged care facilities to Department of Health should be considered
2. Infection control policies must be readily accessible to all nursing staff, not locked in manager's offices
3. Clear protocols needed for faecal sample collection during outbreaks, specifying that aged care facilities are responsible for collecting samples from symptomatic residents
4. Positive pathology results from outbreak investigations must be communicated immediately in writing to nursing staff and treating medical practitioners
5. Clear delineation of roles and responsibilities between treating doctors (responsible for individual patient management) and public health agencies (responsible for outbreak investigation and control)
6. Treating doctors must be informed of the pathogen identified in an outbreak to guide clinical management decisions
7. All test results must be documented in writing and placed on patient medical records
8. When patients are transferred between facilities, all relevant information about identified pathogens must be communicated to ambulance staff and receiving hospitals
9. Medical practitioners must understand that notification obligations are personal and cannot be delegated to nursing staff
10. Early coordination and central control team should be established at the time of outbreak identification
11. Clear communication protocols between nursing staff and visiting doctors regarding test results and outbreak details
12. Training for medical practitioners on notification obligations under Public Health and Well Being Act 2008