Finding into death of Ian Dunlop

Contributing factors

• Failure of nursing staff to follow escalation procedures despite abnormal vital signs
• Misinterpretation of symptoms as post-operative pain and anxiety rather than signs of clinical deterioration
• Inadequate physical examination and clinical assessment by medical staff
• Lack of timely medical review despite objective evidence of deterioration
• Culture of nursing staff making independent judgement calls rather than following Observation Response Chart protocol
• Delayed recognition of heart failure signs including elevated jugular venous pressure
• Policy that did not mandate physical assessment by doctor when contacted about deterioration

Coroner's recommendations

1. Donvale Rehabilitation Hospital to provide the Court with their updated Recognising and Responding to Clinical Deterioration policy as revised following discussion at the Medical Advisory Committee Meeting
2. Update observation chart to include 'displaying anxiety' under 'looks unwell' to highlight that anxiety may indicate clinical deterioration
3. Education of nursing staff to reinforce the need to follow escalation procedures outlined in policy and Observation Response Chart
4. Mandate that medical practitioners physically assess patients when contacted by nursing staff about deteriorating observations, rather than merely documenting telephone conversations
5. Review and strengthen protocols to ensure nursing staff follow Observation Response Chart procedures rather than making independent clinical judgements