Finding into death of Joan Coutts

Contributing factors

• Inadequate triage assessment not accounting for severity of pain
• Inappropriate triage categorization (Category 5) despite severe pain and high-risk features
• Inadequate discharge planning without addressing risk factors
• Failure to complete Discharge Risk Screening Tool
• Lack of documented discussion of social circumstances and support systems
• Inadequate documentation of discharge rationale
• Failure to anticipate complications of multiple rib fractures in elderly patient with comorbidities
• Lack of follow-up arrangements beyond general practitioner referral
• Patient lived alone with limited social support and mobility impairment from severe pain

Coroner's recommendations

1. Ballarat Health Services should consider providing further education to staff about the triage of Emergency Department patients
2. Ballarat Health Services should consider allocating specific responsibility for completion of the Discharge Tool within the Emergency Department to ensure adequate discharge planning occurs and that the rationale for discharge decisions is apparent