Finding into death of Anthony Travaglini

Contributing factors

• failure to locate and review complete clinical history spanning prior admissions
• absence of clinical alert sheet in latest medical file regarding sleep apnoea diagnosis
• clinicians unaware of history of severe sleep apnoea despite documented sleep studies from 2003
• system failure preventing access to earlier clinical records containing sleep apnoea diagnosis
• benzodiazepine and zuclopenthixol combination contraindicated in sleep apnoea not recognised
• failure to seek collateral medical history from available family member (sister, a nurse)
• respiratory depression from sedative medication in context of unrecognised sleep apnoea
• prescription of sedation without knowledge of respiratory risk factors

Coroner's recommendations

1. Ensure complete clinical file retrieval and review prior to commencing treatment for psychiatric patients with prior admission histories
2. Implement clinical alert systems in patient files to flag significant medical conditions such as sleep apnoea
3. Develop electronic patient record systems with mandatory alert sheets and scanning of relevant reports
4. Establish protocols ensuring family and collateral medical history contact when prior medical records are incomplete
5. Review and reinforce guidelines on contraindicated drug combinations (benzodiazepines and zuclopenthixol in sleep apnoea)
6. Implement systems to address identified gaps in consultant-to-consultant communication regarding patient transfers between units