Inquest into the Death of Donald Richard BROADRIBB

Contributing factors

• Failure to recognise rapidly progressive chest infection with subtle presentation
• Focus on abdominal/gastrointestinal symptoms obscured respiratory diagnosis
• Impaired thermoregulation in elderly patient masked fever significance
• Lack of robust secondary medical assessment before discharge
• Incomplete communication during phone consultation with remote doctor
• Doctor did not receive or review triage fax before telephone consultation
• Nursing shift change may have contributed to loss of continuity
• Abrupt communication style at initial triage affected history taking
• Chest x-ray two days prior did not show developing infection
• Patient largely asymptomatic for severity of underlying infection

Coroner's recommendations

1. Secondary medical assessment should routinely be completed prior to patient discharge when patients have not been physically seen by a doctor
2. Improved documentation of remote medical consultations including clear records of clinical findings and decision-making rationale
3. Staff training on recognition of chest infection in elderly patients with impaired thermoregulation
4. Implementation of telehealth systems (Emergency Telehealth Service) to enable direct visual assessment by specialist doctors
5. Expanded hours of telehealth operation to 24/7 coverage when feasible
6. Enhanced triage communication style to obtain comprehensive histories without making patients feel rushed
7. Training in assessment skills for nursing staff on information requirements for remote medical consultation