Coronial
VIChospital

Finding into death of Lydia Maxfield

Deceased

Lydia Maxfield

Demographics

85y, female

Date of death

2016-02-22

Finding date

2020-07-16

Cause of death

Multisystem failure complicating ischaemic heart disease and ischaemic bowel in the setting of recent total knee replacement

AI-generated summary

Lydia Maxfield, 85, died 5 days after elective left total knee replacement at a private hospital from multisystem failure due to ischaemic heart disease and ischaemic bowel. Critical clinical lessons: (1) Multiple abnormal vital signs (low oxygen saturation, hypotension) occurring post-operatively were not escalated appropriately according to hospital observation protocols despite documented variances. (2) Poor communication between surgical and medical teams prevented unified assessment; the operating surgeon was not informed of clinical deterioration over the weekend. (3) Medical reviews by multiple clinicians (anaesthetist, general physician) were not documented in the medical record. (4) Post-operative anti-emetics were continued despite persistent nausea without consulting the anaesthetist as per protocol. (5) Care pathway variances were not discussed with the surgeon. Earlier escalation following observation protocol guidelines, comprehensive medical review including imaging, and better interdisciplinary communication may have enabled timely diagnosis of bowel ischaemia and intervention.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

orthopaedic surgeryanaesthesiageneral medicine

Error types

communicationsystemdelay

Drugs involved

ondansetronmetoclopramideopioid analgesiarivaroxaban

Clinical conditions

ischaemic heart diseaseischaemic bowelsmall bowel obstructionmultisystem failurepost-operative hypoxiapost-operative hypotensionpost-operative nausea and vomitingpulmonary oedemarenal impairmentelevated inflammatory markers

Procedures

total knee replacementfemoral nerve blockintrathecal anaesthesiachest X-rayabdominal X-rayabdominal CT scan

Contributing factors

  • Failure to escalate abnormal vital signs in accordance with hospital observation protocol
  • Non-documentation of medical reviews by multiple clinicians
  • Poor communication between surgical and medical teams
  • Absence of weekend surgical review despite clinical deterioration
  • Failure to escalate persistent nausea and vomiting despite protocol requirements
  • Non-communication of care pathway variances to treating surgeon
  • Delayed recognition of small bowel obstruction/ischaemia
  • Lack of integration of clinical observations across medical team
  • Weekend VMO roster was unfilled and admitting surgeon not notified
  • Absent documented process for communication when patient reviewed by non-admitting medical practitioner

Coroner's recommendations

  1. Implementation of mandatory education and training for nursing staff on effective communication and MPH policies, particularly regarding care of elderly patients in acute settings and use of the AORC (Adult Observation and Response Chart)
  2. Full system review of clinical handover processes to ensure effective communication across all levels
  3. Clear documented process ensuring admitting visiting medical practitioners are notified when their patient is reviewed by another visiting medical practitioner due to clinical deterioration
  4. Ensure VMOs review and understand hospital observation protocols and escalation requirements
  5. Implementation of tools such as ISBAR for clear communication when a patient is deteriorating
  6. Mandatory documentation of all clinical reviews in medical records regardless of changes to management
  7. System ensuring admitting surgeons are informed of weekend roster gaps and arrangements
  8. Education on recognition and response to patient deterioration with scenario-based training
  9. Review of post-operative anti-emetic protocols to specify timeframe for consultant notification if nausea persists
  10. Ensure care pathway variances are communicated to and discussed with treating medical staff
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