Finding into death of Alan John Trevor Deem

Contributing factors

• Right coronary artery dissection during percutaneous coronary intervention
• Significant delay between detection of coronary occlusion (9:12 AM) and referral (approximately 12:45 PM), approximately 6 hours
• Suboptimal record-keeping practices at Sunshine Hospital
• Suboptimal record-keeping practices at Royal Melbourne Hospital
• Lack of contemporaneous documentation of inter-hospital referral discussion
• Reliance on verbal handover without written documentation
• Absence of documented rationale for change in management plan from conservative to surgical
• Unclear timing and decision-making regarding transfer decision
• Inadequate post-operative anticoagulation management
• Right ventricular failure requiring ECMO support
• Multiple post-operative complications including renal failure, hepatitis, and ventilator-acquired pneumonia

Coroner's recommendations

1. Western Health should determine whether the delay in referral was exacerbated by lack of documentation or medical records
2. Western Health should develop and implement measures to ensure referrals are expedited or completed in a timely manner
3. Royal Melbourne Hospital should develop and implement a process to ensure clinicians comply with their own record-keeping policies
4. Royal Melbourne Hospital should develop a toolkit to facilitate clinician compliance with their record-keeping policies
5. Victorian Department of Health should encourage and facilitate the roll-out of CareSync Exchange system or similar program with functionality to facilitate inter-hospital transfer documentation with real-time communication between referring and receiving hospitals