Finding into death of Winifred Jean Carpenter

Contributing factors

• Failure to recognize clinical deterioration despite increasing abdominal distension, elevated white blood cell count, and pain
• Improper dismissal of family concerns about discharge safety
• Failure of junior medical staff to escalate concerns to senior staff
• Lack of physical examination on day of discharge despite clinical indicators
• Delayed dietician referral and inadequate nutritional assessment
• Reliance on text messaging for critical clinical communication rather than verbal handover
• Inadequate documentation of family concerns and junior staff communications
• Lack of awareness and proper implementation of RAISE escalation process
• Transfer of care to locum surgeon on discharge day without continuity of clinical review
• Failure to appreciate pain reporting as indicator of deterioration

Coroner's recommendations

1. Implementation of a Statewide escalation policy in Victoria for family concerns in healthcare settings, similar to the REACH program used in New South Wales and Queensland
2. All family concerns should be identified and actioned appropriately by hospital staff regardless of whether they strictly follow prescribed escalation procedures
3. Strengthen junior medical staff education on mandatory escalation pathways and the requirement to obtain verbal confirmation from senior staff for critical clinical decisions
4. Implement requirement for contemporaneous clinical documentation of all family concerns and clinical discussions
5. Establish pre-admission screening for post-operative patients with low BMI or protracted weight loss
6. Ensure early dietician referral and post-operative nutritional intervention
7. Develop electronic medical record amendments to include pain scale ratings as escalation triggers
8. Strengthen staff awareness and implementation of the RAISE call process with ongoing education for both staff and consumers
9. Ensure continuity of surgical care on discharge days rather than handover to locum surgeons without full clinical review
10. Implement high-risk assessment clinics for patients at elevated risk of post-operative complications