Finding into death of Barry Brown

Contributing factors

• Failure of nursing staff to follow escalation algorithm and call code blue
• Delay in notifying operating surgeon (9:30pm vs. 7:30pm hypotension detected)
• Delay in surgeon attending hospital (2 hours from initial call)
• Inadequate fluid resuscitation in early phases
• Diagnosis of cardiogenic shock rather than hypovolaemic shock
• Confirmation bias in clinical decision-making
• Failure to check central venous pressure
• Failure of senior consultants to attend hospital in person
• Poor inter-specialist communication; reliance on junior doctor intermediaries
• Excessive delay awaiting echocardiogram (2 hours vs. ~30 minutes appropriate)
• Possible unligated cystic artery or dislodged surgical clip

Coroner's recommendations

1. The Western Hospital should provide specific periodic training to nursing staff on strict compliance with escalation algorithms and circumstances for calling code blue
2. The Western Hospital should explicitly include in procedures and protocols the requirement that a surgeon be immediately notified if a post-operative patient experiences hypotension and that the surgeon (or nominee) assess the patient as soon as possible
3. The Western Hospital should formulate and promulgate written policy setting out when on-call and consultant physicians treating one patient should: (A) speak directly to each other rather than managing treatment indirectly through junior physicians or remotely, particularly when one proposes treatment with which another has reservations or when patient condition precipitously changes; and (B) themselves go to the hospital and assess the patient
4. The Australian Medical Council should include in physician training syllabus explicit and detailed material analysing confirmation bias, its nature, manifestation and potentially fatal effects