Inquest into the Death of Mckay-Hall, Julienne Maria

Contributing factors

• Staple gun misfire during initial sleeve gastrectomy not adequately repaired
• Failure to detect or respond to evidence of staple line leak immediately post-operatively
• Delayed recognition of sepsis
• Failure by surgeon to read nursing notes documenting signs of sepsis on 11 November 2007
• Surgeon did not attend hospital to assess patient despite concerning vital signs on evening of 11 November
• Failure to escalate to Medical Emergency Team on 12 November despite vital signs meeting MET criteria
• No observations taken between 2pm and 8pm on 12 November despite patient being critically ill
• Inadequate nursing communication between shifts and between team members
• Surgeon did not review vital signs on 12 November despite having time and patient being visibly severely unwell
• Delayed surgical intervention (staged 30+ hours after leak confirmed on CT)
• Chronic fistula with marked gastric scarring predisposed to air embolism during late procedure

Coroner's recommendations

1. In the event that vital signs of a patient are significantly outside the normal range, the nurse taking the observations should be required to advise the senior nurse of the shift of those changes
2. At the time of the next handover information about any significantly outside the normal range vital signs detected during the shift should be communicated to the next nursing shift
3. There should be an entry in the Integrated Progress Notes relating to abnormal vital signs indicating why they were considered out of range, whether they were improving or getting worse and what action was being taken
4. When observations record vital signs outside the normal range, the next observations should be taken within a short period of time, not left until the next routine observations are required
5. St John of God Hospital Murdoch should put in place a system of audits to ensure that when MET calling criteria are met, MET calls are in fact being instigated and appropriate action is being taken
6. Copy of findings to be forwarded to Department of Health to promote consistency of MET calling criteria and documentation throughout Western Australian public and private hospitals
7. Consideration should be given to standardized coloured observation charts with visual prompts similar to those implemented by St John of God Hospital Murdoch across all Western Australian hospitals