Finding into death of June Olive Pegg

Contributing factors

• failure to arrange colonoscopy following PET scan finding of colonic mass in May 2010
• five-month delay in diagnosis of colonic cancer
• inadequate post-operative surveillance despite high-risk pre-operative status
• failure to investigate paralytic ileus with CT imaging on post-operative day 2
• failure to escalate concerning clinical signs to senior surgeon
• failure to recognize significance of left-sided abdominal pain in post-operative period
• inadequate senior surgeon follow-up (only days 1 and 3 post-operatively)
• poor medical handover between incoming and outgoing junior doctors on day 6
• failure to make MET call when blood pressure met criteria (82/50 at 7.38 PM on day 6)
• administration of frusemide in context of hypotension and oliguria

Coroner's recommendations

1. The Victorian Department of Health and Australian Commission on Quality and Safety in Healthcare should undertake action to raise awareness of healthcare organisations' responsibility to ensure quality documentation of patient care
2. Barwon Health should undertake action to raise awareness of practitioners and clinicians regarding their obligations to provide quality documentation of patient care, including documentation of clinical handover between shifts
3. Barwon Health should encourage staff involved in the management of patients whose death may be reportable under the Coroners Act 2008 to commit to writing a record of their involvement at the first opportunity