Finding into death of Giuseppe Costa

Contributing factors

• Premature removal of intercostal catheter despite persistent pleural effusion on imaging
• Inadequate documentation of pleural fluid drainage quantities and cessation of drainage
• Failure to activate MET call despite vital sign deterioration meeting MET criteria
• Unclear and undocumented modification of MET call criteria written as 'Not for MET Calls'
• Incomplete recording of vital signs not compliant with national standards
• Poor communication of radiological findings to treating clinicians
• Intercostal artery damage during catheter insertion with subsequent uncontrolled bleeding
• Substandard observation and response charting
• Possible lack of clinician awareness of persistent effusion on imaging

Coroner's recommendations

1. Western Hospital Footscray ensure their use of Observation and Response Charts is compliant with the Australian Commission on Safety and Quality in Health Care's National Standards
2. Western Hospital Footscray peruse this Finding to improve their overall management of drainage of pleural effusions, including ensuring adequate documentation of the management of drainage of pleural effusions
3. Western Hospital Footscray explore opportunities to educate all clinical staff to improve their interpretation of chest X-ray results