Finding into death of Madeleine Therese Sobb
Deceased
Madeleine Therese Sobb
Demographics
25y, female
Coroner
Coroner Caitlin English
Date of death
2015-05-22
Finding date
2019-03-01
Cause of death
Airway obstruction complicating laryngeal dilation for the treatment of subglottic stenosis in a woman with spondylo-epi-metaphyseal dysplasia
AI-generated summary
Ms Sobb, a 25-year-old woman with spondylo-epi-metaphyseal dysplasia causing severe airway abnormalities and subglottic stenosis, died from airway obstruction following laryngeal dilation. She was admitted to ICU with asthma exacerbation from respiratory infection, then transferred to a general ward on 20 May 2015. Critical failures included: inadequate ICU-to-ward handover lacking documentation of adrenaline nebuliser use and airway management plan; missing medical review following discharge and after adrenaline nebuliser administration at midnight; non-compliance with four-hourly observation policy (only recorded at 2400H and 0530H); and insufficient documentation of staff communications. Although deterioration may have been precipitous, earlier medical assessment following the adrenaline nebuliser administration—which required doctor notification per the prescription—could have enabled earlier recognition of airway compromise. The hospital implemented substantial improvements post-inquest including mandatory medical review after adrenaline nebuliser administration, improved discharge checklists, and enhanced tracking of recently-discharged ICU patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Inadequate ICU-to-ward handover process lacking documentation of adrenaline nebuliser prescription and airway management plan
- Absence of verbal or face-to-face handover between ICU doctor and ward doctor
- Missing medical review following discharge from ICU
- Missing medical review following administration of adrenaline nebuliser at midnight on 21 May 2015
- Non-compliance with four-hourly observation policy; observations only documented at 2400H and 0530H
- Inadequate documentation of staff communications regarding adrenaline nebuliser authorisation
- Prescription of adrenaline nebuliser as 'PRN' without sufficient explanation of significance may have sent mixed messages to nursing and medical staff
- Reduced seniority and staffing levels overnight
- Lack of explicit requirement in discharge summary for medical review if adrenaline nebuliser administered
- Patient placed in isolation without evidence of individualised care planning for her physical disability
- Difficulty for patient to sleep due to positioning limitations not addressed by ward staff
Coroner's recommendations
- Development of guideline to instruct staff on safe use of adrenaline nebuliser, including who can order it, where it can be administered, escalation process once administered, and monitoring requirements
- Clinical alert to be distributed to all Medical and Nursing staff regarding use of adrenaline nebuliser and new guideline
- Reinforcement with ICU staff that prior to discharge/transfer from ICU, all patient medication charts are to be reviewed to ensure all medications are appropriate for administration in general ward areas
- Clinical lead to receive list of all ICU patients who have been transferred to the ward in the last 12 hours; after-hours cover HMO/ward staff to escalate to Clinical Lead any change in condition of recently discharged patients from ICU
- Implementation program to be developed for Managing Patients with Complex Needs and Disability guideline
- Disability working group to scope alert to social worker for all newly admitted persons with disabilities and special needs, and automated e-referral to social work department
- Implementation of automated anaesthesia information system with all patient data on file
- Development of 'Welcome to Alfred Patient Education' video to include 'Let me know' education
- ICU discharge checklist must be reviewed by Patient Access Nurse
- Formal documentation of handover process and persons notified to improve retrospective review
- Updated Guideline on Minimum Standard of Measuring and Documenting Adult Physiological Observations (implemented March 2016)
Full text
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