Finding into death of Michelle Lorraine Griffin
Deceased
Michelle Lorraine Griffin
Demographics
48y, female
Date of death
2011-03-23
Finding date
2016-04-01
Cause of death
Acute respiratory failure (cerebral hypoxia) in a woman dependent on non-invasive ventilator for breathing assistance, suffering from motor neurone disease
AI-generated summary
Michelle Griffin, 48, with motor neurone disease, died from acute respiratory failure while dependent on non-invasive ventilation (NIV) at home. A carer, Julie Manessis, was caring for her when the humidifier tipped over, water entered the airway tubing, and the NIVs malfunctioned. Manessis was unable to troubleshoot the equipment failure. Key clinical lessons: disability support workers caring for NIV-dependent patients require structured, accredited training beyond brief 'train the trainer' approaches; new backup ventilators of different models require comprehensive carer training; regulatory oversight of non-registered disability service providers was inadequate; and emergency equipment (bag-valve-mask) and anchoring devices for ventilators could improve safety. The VRSS provided appropriate equipment but relied on inadequate informal carer-to-carer training methods.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Water from tipped humidifier entered airway tubing and ventilator circuit
- Carer (Julie Manessis) insufficiently trained and experienced in NIV management and troubleshooting
- Provision of new backup NIV device (different model) requiring additional carer training
- Inadequate 'train the trainer' model reliance by VRSS for carer education
- Oncall Personnel not a registered DHS disability service provider at time of engagement
- Lack of regulatory oversight and standards for non-registered disability service providers
- Inadequate formal training provided to replacement carer prior to shift
- Only informal, brief handover training given to Manessis on 23 March 2011
Coroner's recommendations
- Department of Health and Human Services and/or regulatory bodies should review or establish guidelines regarding expected qualifications and experience of disability support workers employed to care for clients requiring chronic domiciliary non-invasive ventilation
- Department of Health and Human Services should secure funding for establishment of an accredited education course for carers on chronic domiciliary non-invasive ventilation (such as the 'Course in Personal Care Training Using Non-Invasive Ventilation' developed by VRSS), covering practical patient transfer and simulation of emergency response to ventilator failure
- Department of Health and Human Services should review requirements for clinical governance of non-DHS registered disability service providers and consider excluding such organisations from providing disability support workers for NIV-dependent clients
- VRSS should conduct informed internal review of policies and procedures, including: risks and benefits of providing identical versus alternative brand main and backup NIVs; provision of anchoring devices to reduce risk of ventilators tipping; feasibility of including manual airway resuscitation devices (bag-valve-mask kit or resuscitation mask) as safety measures
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