Finding into death of Michael Philip Young

Contributing factors

• Failure to implement spinal precautions on ED admission despite high-risk trauma mechanism
• Incomplete neurological examination at ED and ICU despite paraspinal tenderness and patient-reported back pain
• Failure to recognise chalk-stick fracture risk in context of ankylosing spondylitis and renal bone disease
• Improper positioning of patient on CT table while flat despite documented inability to lie flat
• Use of sedating agents (ketamine, opioids) impairing patient's ability to communicate pain and request repositioning
• Failure to escalate documented new lower limb weakness and sensory loss (11 pm ED assessment, 2 am ICU assessment)
• Anchoring bias: assumption patient's leg weakness was baseline without clarifying with patient or family
• Premature diagnostic closure with focus shifting to hypotension management
• Non-compliance with hospital trauma alert protocol
• Fragmented ED consultant involvement with poor handover
• Failure to involve patient and family carer in problem-solving regarding imaging and positioning
• Resulting complete spinal cord injury (ASIA Grade A) leading to paraplegia and chronic pain
• Secondary complications: severe pressure ulcers from immobility, ongoing hypotension, sepsis from wounds, inability to tolerate dialysis

Coroner's recommendations

1. Ensure the Trauma Alert protocol is communicated to all ED staff frequently and compliance with protocol monitored
2. Raise awareness and importance of trauma care on admission to ICU (i.e. tertiary assessments), following a fall with consideration to other relevant co-morbidities
3. Optimize the handover process between ED and ICU
4. Promotion of the Disability Liaison service across Emergency Service
5. Improve communication with families and carers by ensuring the organisation-wide Family/Carer Concern process is embedded into ED provision of care