Finding into death of Damien Mark Stone

Contributing factors

• Pelvic fracture sustained during hospital admission
• Inadequate pain assessment in non-verbal patient
• Delay in escalation of care for uncontrolled pain
• Limited engagement with family and carers in care planning
• Absence of Disability Liaison Officer involvement
• Incomplete risk assessment and care planning on admission
• Opioid-related respiratory depression following adequate but insufficient analgesia
• Seizure on 26 September 2022

Coroner's recommendations

1. Barwon Health should accompany release of revised Pain Management Policy with training for clinical staff in assessing and managing pain in people with cognitive impairment, especially those with communication difficulties.
2. Barwon Health should consider nursing staff use of the Health Passport document where appropriate, especially for non-verbal patients, to guide information collection from people with disability, their families and carers to inform patient-centred care planning.
3. Barwon Health should implement professional development for nursing staff on providing patient-centred care to patients with cognitive disability, potentially led by 'disability champions' under the Inclusive Victoria State Disability Plan 2022-2026.
4. Review of MET call procedures to ensure uncontrolled pain is well articulated as a reason for MET calls.
5. Forums for clinical staff to increase understanding of rapid response systems and improve culture of calling METs.
6. Review of Escalation to Consultant procedure to empower nursing staff when patient care issues have not been resolved.
7. Barwon Health Disability Liaison Officer team should review this case and develop a plan to improve understanding of their role with clinical directorates to ensure appropriate referrals.