Finding into death of Keith Walter Sharp

Contributing factors

• Blunt traumatic bilateral vertebral artery dissection
• Approximately 4.5 hour delay in ordering and completing imaging investigations
• Poor documentation by emergency department medical staff
• Lack of senior emergency department medical staff supervision
• Emergency physician in charge unaware of initial CT results and delays
• Failure to incorporate state-wide trauma referral pathways into local hospital policy
• Nursing staff unable to remain with patient during MRI due to workload
• Delayed recognition of deterioration risk
• Lack of verbal reporting of critical MRI findings to clinical staff

Coroner's recommendations

1. Albury Wodonga Health Safety and Quality Department should repeat their investigation with an external expert in emergency department trauma process management to identify better opportunities for system improvements
2. Education of medical staff regarding medico-legal obligations regarding documentation
3. Development of policy that category I trauma cases are overseen by the senior ED doctor
4. Incorporation of trauma referral pathways into local policy including display of ARV posters in resuscitation rooms
5. Updating policy for nurses and doctors to stay with critically ill patients when transported out of department
6. Implementation of rapid screening of CT pan-scan images by radiologist while patient is still in scanner
7. Consideration of whether CT angiogram alone would suffice rather than staged imaging
8. Direct communication of potentially critical CT results to emergency physician in charge