Inquest into the Death of Nielson, Melissa Ann

Contributing factors

• failure to adequately communicate clinical concern via EDIS system
• misspelling of patient name in EDIS (NIELON vs NIELSON) preventing information integration
• triage nurse did not review discharge letter from transferring hospital
• inadequate triage score - patient given ATS 3 instead of ATS 2
• patient placed in unmonitored minor theatre without vital signs recorded
• no cardiac monitoring despite known cardiac risk factors and uncertain diagnosis
• delayed ambulance transfer (3.5 hours) resulting in outdated pathology results
• separation of transfer documentation from patient on arrival at receiving ED
• insufficient handover between doctor accepting transfer (Dr F.) and ED staff
• system overload - hospital ED operating at 136% capacity, ambulance service under extreme demand
• no secondary nursing assessment or vital signs taken before arrest occurred

Coroner's recommendations

1. Doctors accepting patients on doctor/hospital transfer ensure they provide RPH ED with clinical information supporting their reason for accepting transfer at the time the decision is made and request it be placed on EDIS
2. RPH ED considers the use of smart computers to interrogate entries to EDIS where there may be an error in name spelling or date of birth to assist with effective repopulation of patient's files
3. Triage assessments be done by sighting appropriate discharge/transfer information, especially where they provide a baseline for further assessments
4. Team leaders in ED making decisions about appropriate placement of patients awaiting assessment ensure they understand the significance of transfer documents to ensure decision-making for placement is as informed as possible
5. RPH ED consider the facility of introducing some vital sign observations at triage and any following primary assessment rather than reliance on ABC alone where there is likely to be a delay before secondary assessment and/or medical assessment due to pressure on ED when operating over capacity