LONG June

Contributing factors

• Inadequate supervision of junior medical officer (intern with 5 months experience)
• Failure to involve respiratory specialists despite patient admitted under Respiratory Medicine Department
• Over-reliance on oximetry without adequate arterial blood gas monitoring
• Misdiagnosis as acute asthma rather than chronic hypercapnic respiratory failure
• Failure to read and incorporate previous clinical notes and observations
• Oxygen therapy without monitoring for hypoventilation and CO2 retention
• Failure to recognize signs of progressive respiratory failure overnight
• Inadequate documentation of clinical examination at 4am
• Delayed escalation to senior medical staff and respiratory specialists
• No ICU bed availability at primary hospital requiring emergency transfer

Coroner's recommendations

1. Public Health Branch to provide general warning to all hospitals and medical colleges regarding the dangers of relying on oximetry in the management of respiratory failure, with specific attention to the importance of regular arterial blood gas tests for monitoring carbon dioxide levels
2. Medical colleges should emphasize through relevant channels the need for accurate and timely note-taking and recording of vital signs, with consideration of computer technology to develop early warning mechanisms for routine vital signs monitoring
3. Public Health Branch to develop a standardised investigation protocol for hospitals for all serious adverse medical events (injury or death), including data collection and reporting mechanisms to ensure problems identified are disseminated throughout the hospital and medical system in a timely way