Finding into death of Ronald William Beaumont

Contributing factors

• Acute myocardial infarction (NSTEMI) following second shoulder surgery due to supply-demand mismatch rather than thrombotic occlusion
• Multiple organ failure including renal and hepatic dysfunction
• Post-operative wound dehiscence and infection
• Inadequate pre-admission documentation and medication management communication
• Unclear process for out-of-hours direct inpatient admission regarding anticoagulation plan
• Inadequate family communication at time of first heart attack
• Inadequate post-death care pathway completion on non-palliative ward
• Possible contrast-induced nephropathy, acute tubular necrosis, autoimmune renal damage, or antibiotic-associated interstitial nephritis

Coroner's recommendations

1. Establish clear process for out-of-hours direct inpatient orthopaedic admissions requiring formal history and examination by Hospital Medical Officer or covering specialty HMO, medication charting, and collaborative care plan with on-call registrar, documented in electronic medical record
2. Communicate admission plan via orthopaedic handover worksheet and to covering overnight/weekend orthopaedic team
3. Provide education to nursing staff on 5FN ward regarding post-death section of care of the dying pathway, including family communication, next steps information, and bereavement support documentation
4. Review clinical pathway for Direct Admission Process to clarify home unit responsibilities regarding patient assessment and care plan at admission
5. Adopt conservative approach to Sentinel Event reporting with use of CAE and Safer Care Victoria hotline/email when doubt exists
6. Establish clearer and more consistent escalation pathway for Sentinel Event recognition and reporting
7. Notify all units of 24/7 availability of palliative care advice
8. Improve communication with families during end-of-life care occurring outside palliative care unit