Finding into death of Beverley Pattinson

Contributing factors

• Failure to review ambulance notes documenting dark bile vomiting
• Failure to recognize colour of vomitus as indicator of lower bowel pathology
• Inadequate initial clinical examination or documentation of hernia sites
• Failure to incorporate known hernia repair requirements into differential diagnosis
• Absence of abdominal imaging (X-ray or CT) despite indicators
• Over-reliance on absence of abdominal pain to exclude bowel obstruction
• Missed interpretation of significant acidosis on blood tests
• Delayed IV fluid initiation
• Failure to insert nasogastric tube for decompression
• Atypical presentation with improvement in renal function masking ongoing obstruction

Coroner's recommendations

1. AHPRA notification for investigation of Dr Z.'s involvement in assessment and treatment
2. Yarram and District Health Service to ensure all patient records including GP records sourced and available for treating practitioners
3. Yarram to ensure ambulance records reviewed by treating practitioners and nursing staff from time of arrival
4. Yarram to ensure staff aware of necessity to incorporate ambulance records into initial notes and assessment
5. Yarram to ensure all medical practitioners take full and comprehensive history with notes incorporating all observations and examinations, not just positive findings
6. Yarram to ensure notes initialled by authoring staff
7. Yarram to ensure record keeping follows best practice, investigating electronic methods versus paper-based
8. Yarram to provide further training to medical practitioners on interpretation of blood test results
9. Yarram to establish protocols for communicating with other hospitals regarding referred patients to ensure relevant observations, examinations and results communicated back