Finding into death of Christopher Albert Nance

Contributing factors

• inadequate and incorrect nursing observations during early hours of 18 September 2015
• four-hour discrepancy between medical record and pacemaker-recorded time of death
• post-operative delirium
• possible alcohol withdrawal
• analgesic medications (tramadol, oxycodone)
• family concerns not escalated for medical review

Coroner's recommendations

1. Implementation of electronic 'point of care' documentation system requiring nurses to record observations directly at bedside with timestamped data transmission
2. Introduction of 'Code Worried' protocol enabling family members to escalate concerns through formal three-tier escalation pathway
3. Development of formal procedures for families to escalate concerns about patient care
4. Implementation of 'leader rounding' process by senior nursing staff including family members to address unresolved concerns
5. Review and update of Physiological Observations Protocol to emphasise bedside rounding for both patient experience and safety confirmation
6. Counselling and guidance for staff involved in care delivery to ensure compliance with documentation standards